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Andy’s Angels Application Form
American Office Solutions
2019-02-05T18:43:53+00:00
Our mission is to educate on opiate and drug use. We are able to provide support and help to the families suffering from opiate addition. This non-profit organization is in honor of Andrew Michael Hirst who passed away from a Heroin overdose on May 17th, 2010. Our board will review this application and get back to you in a timely manner.
Who is fillling out this application
*
Individual in need
Family Member
Sponsor
Is the person seeking assistance under the age of 18?*
*
Yes
No
Name
*
First
Last
Current Home Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Zip
*
Phone
Email
*
Birth Date
*
Where are currently residing?
*
Home
Apartment
Parents Home
Friends Home
Relative Home
Treatment Facility
Incarcerated
Homeless
What form of treatment have you received? Please explain.
*
Inpatient, Outpatient, counseling, amount of time spent in the treatment and dates provided.
Are you currently in a treatment program? If yes, where and what program.*
*
Please name the treatment program, where it is located and when the treatment began.
Are there any addictions in your home?
*
Yes
No
Who is helping support your goal in sobriety?
*
Parent
Sibling
Spouse/Significant Other
Relative
Counselor
Friend
Sponspor
I do not have a support person in place.
How are they helping to support you? Please Explain.
*
Example: Financially, Emotionally
What kind of assistance are you seeking.
*
Financial
Emotional
Legal
Please explain the type of assistance that you are in need of.
*
Example: Dollar amount, percentage, Support group,
Have you ever overdosed?
*
Yes
No
Please provide us with a detailed story of your battle with addiction.
*
Tell us how your addiction began, the struggles you have faced with addiction, the emotions tied to your choices, etc..
Can we share your story?
*
Yes
No
How did you hear about Andy's Angels?
Do you have insurance?
*
Yes
No
If applicant is under the age of 18 please provide us with the information below.
Name of parent/legal guardian, Address, City, State, Zip, Phone, Email.
Type Name and Date of Parent or Legal Guardian (Electronic Signature)
Do you have an Andy's Angels Contact?
*
Yes
No