Please fill out the following form to give us information about you or about the loved one for whom you are applying.

How did you hear about The Lovato Scholarship at CAST Recovery? Name Age Birthdate Phone Number Email Home Mailing Address Current Living Situation (Check all that apply)

Living alone	Living with children	Living with parents
Living with extended family	Living with roommates	Living in a shelter
Living with spouse	Living in sober living	Living on the streets
Living with unmarried partner
Other
If other, please explain:

Relationship Status (Check all that apply)

In a civil union	Divorced	Domestic partnership
Engaged	Married	Open relationship
In a relationship	Separated	Single
Widowed
Other
If other, please explain:

Have you been in therapy before? Yes No
If yes, please describe: Have you received any diagnosis from a mental health professional? (Check all that apply)

ADHD	Antisocial Personality Disorder	Anxiety Disorder
Bipolar Disorder	Borderline Personality Disorder	Depressive Disorder
Obsessive Compulsive Disorder	PTSD	Schizophrenia
Other
If other, please explain:

Briefly list your main concerns about your mental health or unhealthy behaviors: (100 words max) Are you currently in treatment? Yes No
If yes, please include the following: Name of facility/facilities Type of treatment (such as residential, IOP, etc.) How long you have been in treatment Expected date of discharge Have you had any previous treatment for mental health? Yes No
If yes, please include the following: Name of facility/facilities Type of service Dates of participation Length of treatment Successfully compleated and discharged? Have you had any previous treatment for addiction? Yes No
If yes, please include the following: Name of facility/facilities Dates of participation Length of treatment Successfully compleated and discharged? Please list any medications and the dosages you are currently taking: Please list all medications you have been prescribed in the past and the dosages: Please tell us about your support system by describing the support you have in the following areas: Family: (100 words max) Social: (100 words max) Spiritual: (100 words max) Financial: (100 words max) Clinical: (100 words max) Medical: (100 words max) Do you have any outstanding legal issues? Please describe any outstanding warrants, any past/current/pending charges, upcoming court dates, etc. Are you currently employed? Yes No

If not, what sources of income or financial support do you have?(100 words max)

Please list any work experience and any work goals: (100 words max) Please list your education and any educational goals: (100 words max) What is your personal vision for your future? (100 words max) What goals do you hope to accomplish through treatment at CAST? List and describe a minimum of 3 personal goals. (100 words max) How do you believe you will benefit from CAST's Intensive Outpatient Program (e.g., groups, therapy, coaching)? (100 words max) How do you believe you will benefit from CAST's Transitional Living? (100 words max) If you are awarded the Lovato Scholarship at CAST Recovery, how will you benefit the community? (100 words max) How will you receiving this scholarship contribute to creating a better world around you? (100 words max) What will you do after treatment? Please tell us what your exit plan is for when your scholarship comes to an end. (100 words max) Are there any foreseeable complications or issues that may prevent you from completing the treatment recommendations at CAST? (100 words max) What makes you a good candidate for this scholarship? Help us understand why you want this opportunity. (100 words max) If you are currently in a clinical program or facility, it is important for us to be able to communicate with your current provider. If you are awarded the scholarship, are you willing to sign an authorization for us to receive information from your current provider in order to facilitate the coordination of your care? Yes No If you are a finalist for the scholarship, do you consent to a background check? Yes No