Apply for a Treatment Scholarship

Apply for a Blackburn Foundation treatment scholarship online. You can fill this out for yourself, or help someone you love or a client fill it out.

Before you start

  • The application has 7 short sections and takes about 20 to 30 minutes.
  • Your answers are saved in this browser tab as you go, so you can go back and forth between sections.
  • If you have them, have your last 2 pay stubs and a recent bank statement ready to attach. You can also send them later.
  • At the end you will read the agreement and sign with your finger or mouse.

Questions or trouble with the form? Call (888) 305-5422 or email info@theblackburnfoundation.org.

01General Information

The rest of this form is about the applicant.

Street, city, state and ZIP.

Only the last 4. Please do not enter your full number here. If we need it, we will ask by phone.

Employer, position and how long. If you are a student, please say where and what you study.

Write N/A if this does not apply.

    If you answered yes above, please attach them here. PDF, JPG, PNG or HEIC, up to 6 files, 15 MB each. You can also send them later.

    02Financial History

    Write N/A if nothing.

    03Medical and Legal History
    04Use History
    05Reasons for Seeking a Scholarship

    Be as specific as you can.

    06Support Network
    07Agreement

    Please read each statement and check the box to agree. Then print your name and sign below.

    Affirmation of Accuracy

    I affirm and warrant that all information provided on this application, or to The Blackburn Foundation, whether verbally, in writing, or through any other means, is true, accurate, and complete to the best of my knowledge and belief. I understand and acknowledge that any inaccuracies or omissions may compromise the purpose of any financial assistance or scholarship provided by The Blackburn Foundation.

    Confidentiality Agreement

    I acknowledge and understand that the information provided on this form is confidential. I understand that the purpose of collecting this information is to assess my eligibility for financial assistance, scholarship, and other resources provided by The Blackburn Foundation, and to better understand my circumstances for the purpose of providing support. I hereby grant consent to The Blackburn Foundation to collect, use, and store the information provided on this form for the sole purpose of evaluating my application for financial assistance or scholarship. I understand that this information may be shared with relevant staff, volunteers, or authorized personnel involved in the decision-making process. I further acknowledge that The Blackburn Foundation is committed to maintaining the confidentiality and privacy of my personal information in accordance with applicable laws and regulations. My information will not be disclosed to any third party without my explicit consent unless required by law.

    Verification Authorization

    I authorize The Blackburn Foundation to verify the accuracy and truthfulness of the information provided on this form. This authorization includes, but is not limited to, contacting relevant individuals, organizations, or third parties to corroborate the accuracy of the disclosed information. I understand and agree that this verification process is essential to ensure the integrity and accuracy of the information provided. Such verification may occur during the term of this Agreement and any extension thereof. I further acknowledge that failure to cooperate with or impede the verification process may be considered a material breach of this Agreement.

    Sign with your finger or mouse.

    Date:

    * Required. Your answers are encrypted and seen only by the people reviewing your application.

    Your information is private and encrypted. It is used only to review your application. Privacy Policy. Submitting an application does not guarantee a scholarship.

    What happens next

    1. We review your application.
    2. We call to learn more.
    3. We build a plan with you and the treatment team.

    Read the FAQ, or learn what a treatment scholarship is and other ways to pay for treatment. Applying for someone else? Read how to help a loved one get into treatment.

    In danger right now?

    Call 911. For a mental health or substance use crisis, call or text 988. Free, confidential, 24 hours a day.

    Talk with
    the Foundation

    Call(888) 305-5422

    12326 Venice Blvd
    Los Angeles, CA 90066

    Emailinfo@theblackburnfoundation.org

    In crisis? Call or text 988.