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How did you hear about Wasatch? (*)

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Name: (*)

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Birthdate: (*)

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Phone: (*)

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Address: (*)

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Email: (*)

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Do you have Health Insurance (*)

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Health Insurance company's name:

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Type of Health Insurance:

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Health Insurance ID Number:

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Health Isurance Group Number:

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Health Insurance Company's Phone Number:

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Martial Status (*)

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Name of Significant Other:

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Childern (list name, ages, custody, and living arrangements for each child):

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Mother's Name and Contact Number:

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Mother's Address

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Father's Name and Contact Number:

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Father's Address

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Current and previous physician's names and contact numbers:

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Any Previous therapist/counselor(s) name and contact numers(s):

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Current Counselor's Name, Email, and Contact Number:

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Drug(s) of Choice:

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Where were you living before treatment, or if not in treatment, where are you currently living:

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If you are in treatment, what is the name of the facility, type of treatment (such as residential, IOP, etc.) and how long you have been in treatment:

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If in a residential treatmnet program, what is your access code?

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What is your expected date of discharge:

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How was your current treatment paid for:

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Have you had any previous treatment in addicitoin? If yes, please include name of facility, date of participation, how long the was, and if it was successfully completed:

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List any other medical or psychological conditions for which you are currently being treated or have been in the past and include names of medical and clinical providers and any medications you are currently prescribed of have been prescribed:

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List any names of medicial and clinical providers and any medications you are currently prescribed or have been prescribed in the past.

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Please detail the kind of support you currently have in these areas:

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Family:

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Social:

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Spiritual (including ecclesiastical leader such as a Pastor or an LDS Bishop, if applicable): (*)

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Clinical: (*)

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Medical: (*)

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Financial: (*)

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Do you currently have any outstanding legal issues? Please include any outstanding warrants and any past/current/pending charges, upcoming court dates etc.

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Are you currently employed? If not, how are you currently being provided for?

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What job opportunities will you pursue during your stay in sober living and do you have any leads or prospects already?

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What kind of work experience do you have and in what field?

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Do you have a degree or other vocational training, do you plan to pursue more school, and if so in what area?

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If you don't have a degree or other vocational training, do you plan to pursue more school, and if so in what area?

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What can you offer as your finanical contribution to your stay in sober living if a scholarship is awarded to you?

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What is your history with substance abuse?

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Why should we consider you for a scholarship? Please feel free to advocate for yourself.

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If you are not eligible for a scholarship, what are you alternative plans:

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Are you aware of the six-month to one-year commitment you will be making if you are awarded the Scholarship? (*)

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Are you willing to volunteer as a mentor for Wasatch Scholarship Foundation (*)

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Are there any foreseeable complications or issues that may prevent you from completing the treatment recommendations if you are awarded a Scholarship?

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Do you have any special circumstances that we should consider?

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If you are currently in inpatient treatment, your primary counselor must submit a discharge summary within two days of submitting this application. Do you understand this requirment? (*)

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Requirements for Accepted Participants ___ Following the recommendations of your Residential Treatment Program, your Individual counselor, and Aftercare Plan. ___ Participating in Weekly Drug and Alcohol Testing. ___ Following the Requirements of the Sober Living. ___ Maintaining contact with Mentor at least bi-monthly. ___ Volunteering for Wasatch after Participation is completed. Because funding is limited and the funds provided to scholarship an individual participant reduce Wasatch Scholarship Foundation’s ability to help other willing and committed applicants, we ask that you exhaust all other resources including family, friends, church and community resources. Wasatch Scholarship Foundation will also enforce the following: If the Participant leaves, is asked to leave by Sober Living, or fails to complete any of the requirements for Participation, the Participant will be billed for the full amount of tuition paid by Wasatch Scholarship Foundation. _____ The amount collected will be used to provide scholarships to other qualified applicants.

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I have read, understand and agreed to the requirements of being an accepted Participant of Wasatch Scholarship Foundation

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(*)


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