Living In Great Hope Today
516 Light Foundation welcomes you to the Sober Living (Recovery Housing) scholarship application.
The information you provide is confidential and will NEVER be shared or sold unless the recipient gives explicit consent.
We prioritize working diligently to respond to your requests and provide you with assistance. We understand that this may be a stressful time, and we recognize that this application asks about sensitive topics. We need you to know that we care for you and hope to help you. The Board of the 516 Light Foundation is made up of volunteers and are likely to take a week or two to reply to your request. If you feel like you are in a crisis and need immediate support, call The National Suicide Prevention Lifeline at 1-800-273-8255.
We are grateful for your participation and wish you all the best. Please be advised duplicates applications (those who have already received a 516 Sober Home scholarship) and unfilled questions will be automatically rejected.
By submitting this scholarship application form to 516 Light Foundation you are granting 516 Light Foundation permission to:
a) use your answers in a de-identified data set (your name, recovery home address, phone number, email address, won't be included) for research analyses.
b) contact the provided recovery residence directly.
c) contact you as the recipient for follow up.
Do you understand and agree to have your application included in this data set and for 516 Light Foundation to reach out to contact your recovery home directly?*
Yes No
What is today's date:*
What is your first name and last name?*
*
Please confirm your email address:*
What is the best phone number for you?*
What is your date of birth?*
Which of the following most closely aligns with your racial identity? (select all that apply)*
American Indian or Alaska Native Asian Black/ African American Latino or Hispanic Native Hawaiian / Pacific Islander White/Caucasian Bi-racial Multi-racial Other Prefer not to answer
How would you describe your gender identity?*
Male Female Gender non-binary Agender Genderqueer Transgender Other Prefer not to answer
Are you currently working or in school? (select all that apply)*
Full- time work Part-time work Full-time or part-time in school Neither work nor in school On disability Other
IF OTHER work/school, please specify:
Have you served in the military?*
What is your highest level of education?*
Eighth grade or lower Partial high school High school graduate GED Trade school Partial college College graduate Graduate school or beyond
What is your religion? (select all that apply)*
Christian (Catholic, Protestant) Buddhist Jewish Islamic / Muslim Atheist (Do not believe God exists) Other
If OTHER Religion, please specify:
What is your current relationship status?*
Married or living with someone as if married Non-cohabitating relationship (in a relationship but we do not live together) Single Divorced or Separated Loss of long-term partner or Widowed Prefer not to answer
Are you entering recovery from any of the following settings? (Select all that apply)*
Residential Alcohol or Other Drug Treatment Program Incarceration Homelessness Behavioral Health Hospital Home No, not coming from any of these settings
Which of these categories best describes your total combined family income for the past 12 months?*
Less than $25,000 $25,000-$49,999 $50,000-$74,999 $75,000-$99,999 $100,000-$149,999 $150,000 or more Don't know/not sure
Are you covered by health insurance? (Check all that apply)*
Yes, military Yes, employer-sponsored Yes, individual Yes, Medicare Yes, Other No
If OTHER health insurance, please specify:
What are the primary substance(s) that brought you to your desire for recovery? (Please check all that apply)*
Adderall Alcohol Ambien Ativan Nembutal (pentobarbital) Bath Salts Benzodiazepines ("Benzos") Cocaine (Coke) Codeine Concerta Crack Demerol Dilaudid DMT DXM (Robo, Dextromethorphan) Fentanyl Flakka GHB Hallucinogens (Ayahuasca, Mescaline/Peyote, Salvia, Psycilocybin) Heroin Hydrocodone (Vicodin, Norco, Zohydro) Imodium (Loperamide) Inhalants K2 Ketamine Khat Kratom Librium LSD (Acid) Lunesta Magic Mushrooms/Shrooms Marijuana (Pot, Weed, Cannabis) MDMA (Ecstasy/Molly) Methadone Methamphetamine (Crystal Meth) Morphine Opioids PCP (Angel Dust) Rohypnol (Roofies, Flunitrazepam) Spice Steroids Suboxone Tobacco/Nicotine (Vaping)
Other (Please specify)
Do you live in recovery housing now?*
When did you move into your recovery home? (Select one option)*
0-3 months 4-6 months 7-9 months 10-12 months More than a year Not applicable
What is your confirmed move-in date for your recovery home?*
Have you ever lived in a recovery house (also known as sober living) or other recovery-based residence before?*
If yes, how many times?
1 2 3 4 5 or more Not applicable
What was your longest length of stay?*
Will (or are) any of your child(ren) staying with you in your recovery home?*
*Your response to this question is optional and will not be part of determining whether you are awarded a scholarship. We are interested in understanding the unique needs of people in recovery who have children so that we are able to think about ways to support people in this situation.
Yes No I don’t have children Prefer not to answer
If at least one of your children will be coming with you to recovery housing, please list the age(s) of each child that will be coming with you.*
516 Light Foundation will reach out to your named recovery home to confirm that you are scheduled to move in or are currently residing there, and if you are selected to receive a scholarship, to organize payment.
Applicants must provide a professional email address for the recovery home contact person in their application. If the applicant includes their own email address (or another personal email address), in place of a staff member/elected officer contact person, they will not be eligible to receive a scholarship. If a person does not know the correct email address for a staff person/elected officer at their recovery home yet, they should not proceed with the application.
Please provide your recovery home staff contact information (or elected officer if at an Oxford House) below:
Name of your recovery home*
Name of a staff contact person (or elected officer if you're at an Oxford Home) at your recovery home*
Professional email address of staff contact person/elected OH officer listed above*
Phone number of your recovery home, including area code*
Mailing address of your recovery home*
City and State where your recovery home is located*
Zip Code where your recovery home is located*
What is your monthly rent amount at the recovery home you will be moving into?*
$0 - $500 per month $501 - $750 per month $751 - $1,000 per month $1,001 - $1,500 per month $1,501 or more per month Unknown
Use this part of the application to see how much money you spend in a month. Then, use this month’s information to help you plan next month’s budget.
Month*
Year*
Income
Monthly Total
Paychecks (salary after taxes, benefits, and check cashing fees)*
Other income (after taxes) for example: child support*
Total monthly income*
Expenses Monthly total
HOUSING
Rent or mortgage*
Renter's insurance or homeowner's insurance*
Utilities (like electricity and gas)*
Internet, cable, and phones *
Other housing expenses (like property taxes)*
FOOD
Groceries and household supplies*
Meals out*
Other food expenses*
TRANSPORTATION
Public transportation and taxis*
Gas for car*
Parking and tolls*
Car maintenance (like oil changes)*
Car insurance*
Car loan *
Other transportation expenses*
HEALTH
Medicine*
Health insurance*
Other health expenses (like doctors' appointments and eyeglasses)*
PERSONAL AND FAMILY
Child care*
Child support*
Money given or sent to family*
Clothing and shoes*
Laundry*
Donations*
Entertainment (like movies and amusement parks)*
Other personal or family expenses (like beauty care)*
Fees for cashier's checks and money transfers*
Prepaid cards and phone cards *
Bank or credit card fees*
Other fees*
OTHER
School costs (like supplies, tuition, student loans)*
Other payments (like credit cards and savings)*
Other expenses this month*
Total monthly expenses*
Maybe your income is more than your expenses. You have money left to save or spend.
Maybe your expenses are more than your income. Look at your budget to find expenses to cut.
1) Having a sense of purpose in life is important to my recovery journey.*
Agree Disagree
2) I am able to concentrate when I need to.*
3) I am actively involved in leisure and sport activities.*
4) I am coping with the stresses in my life.*
5) I am currently completely sober.*
6) I am free from worries about money.*
7) I am actively engaged in efforts to improve myself (training, education and/or self-awareness).*
8) I am happy dealing with a range of professional people.*
9) I am happy with my personal life.*
10) I am making good progress on my recovery journey.*
11) I am proud of my home.*
12) I am proud of the community I live in and feel a part of it.*
13) I am satisfied with my involvement with my family.*
14) I cope well with everyday tasks.*
15) I do not let other people down.*
16) I am free of threats or harm when I am at home.*
17) I am happy with my appearance.*
18) I engage in activities and events that support my recovery.*
19) I eat regularly and have a balanced diet.*
20) I engage in activities that I find enjoyable and fulfilling.*
21) I feel physically well enough to work.*
22) I feel safe and protected where I live.*
23) I feel that I am in control of my substance use.*
24) I feel that I am free to share my own destiny.*
25) I get lots of support from friends.*
26) I get the emotional help and support I need from my family.*
27) I have a special person that I can share my joys and sorrows with.*
28) I have access to opportunities for career development (job opportunities, volunteering or apprenticeships).*
29) I have enough energy to complete the tasks I set myself.*
30) I have had no 'near things about relapsing.*
31) I have had no recent periods of substance intoxication.*
32) I have no problems getting around.*
33) I have the personal resources I need to make decisions about my future.*
34) I have the privacy I need.*
35) I look after my health and wellbeing.*
36) I make sure I do nothing that hurts or damages other people.*
37) I meet all my obligations promptly.*
38) I regard my life as challenging and fulfilling without the needs for using drugs or alcohol.*
39) I sleep well most nights.*
40) I take full responsibility for my actions.*
41) It is important for me to be involved in activities that contribute to my community.*
42) In general, I am satisfied with my life.*
43) It is important for me to do what I can to help other people.*
44) It is important to me that Imake a contribution to society.*
45) My living space has helped to drive my recovery journey.*
46) My personal identity does not revolve around drug use or drinking.*
47) There are more important things to me in life than using substances.*
48) What happens to me in the future mostly depends on me.*
49) When I think of the future, I feel optimistic.*
50) I have a network of people I can rely on to support my recovery.*
Are they any of the past 50 questions you would like to expound on?*
How did you hear about this 516 Light Foundation scholarship opportunity?*
Through a professional (i.e., therapist, case manager, doctor) Someone at the recovery house told me about it. Someone at the treatment center told me about it. I heard about it from someone in the recovery community. Other (Please specify)
Are you currently in a treatment center?*
Please provide your current treatment center’s information (type n/a if not applicable)*
Are you working with a sponsor or mentor? If so, please provide name and number for reference.*
How much money are you requesting for this scholarship?*
How would a scholarship from 516 Light Foundation be helpful?*
Please add signature.*
Applicant completed signature.*
True False
*Required Fields