Andy's Angels Application Form

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*

Zip*

Phone

Email

Birth Date*

Where are currently residing?*

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?*

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