Submit Application

Please fill out all required fields marked with *

Access Code Required

To submit an application, you need a valid access code. This code changes weekly on Sunday. Please contact an administrator to obtain the current code.

New Application Submission

Fields marked with * are required

First Name *

Middle Name (Optional)

Last Name *

Date of Birth *

Email *

Phone Number *

Sobriety Date *

Oxford House Name *

Weekly EES Amount *

Have you moved in? *

Are you receiving any other financial assistance?

Have you reached out to any other charities to request help? If so, who? *

Total Charity Assistance Received

Current Circumstances *

In a few short sentences, describe your current circumstances

Recovery Plan *

Describe your recovery plan

Additional Information

Drug of Choice *

Are you coming from corrections? *

Age Range *

Are you a veteran? *

In the last ninety days have you been in a treatment center, detox, or treatment program?

Access Code

Access Code *

Enter the access code provided by an administrator. This code changes weekly.

By submitting this application, you understand that this does not guarantee you will receive funding.