Request Financial Assistance

Helping Vermonters In Recovery

Jenna’s Promise will provide financial assistance to those seeking recovery. Candidates are those who meet all initial conditions for entry into a sober home, but lack basic funding.

After a short review process of the application, we will require a brief telephone conversation with the applicant to ensure accuracy, discuss goals and personalize our interactions. We also request permission to share their ongoing story on our web site to inspire others to come forward.

Contact information is never displayed, sold or distributed to anyone outside of Jenna’s Promise organization. Applicants may also remain anonymous.

Submit Application To Jenna's Promise

First Name *

Last Name *

Email Address *

Phone Number *

Address *

Town/City *

Zipcode *

Date Of Birth *

Age *

Gender *

Marital Status

Do You Have Children? *

If Yes, How May Children?

If Yes, Are You The Children(s) Guardien?

Are You Currently in Recovery? *

Drugs, Alcohol or Both

Are You Currently In Treatment? *

Case Worker or Authority

Case Worker or Authority Phone Number

Tell Us More About Yourself

Your Goals *

Why Do You Require Financial Aid? *

To Inspire Others, Would You Like To Share Your Story On Our Website?

Yes
No
Not Sure

I hereby request and authorize: Jenna’s Promise To disclose to or obtain information from Name of Person or Agency: The following type(s) of information from my records (and any specific portion thereof):

All Medical Records, Including History and Physical Exams
Alcohol and Drug Abuse Treatment/Use and Records related to substance use.
Other [for the purpose of]: Coordination with Jenna’s Promise staff following admission to Jenna’s Promise.

All information I hereby authorize to be obtain from this agency will be held strictly confidential and cannot be released by the recipient without my written consent. I understand that this authorization will remain in effect for:

Ninety (90) days unless I specify an earlier expiration date
One (1) year
The period necessary to complete all transactions on account related to services provided to me.

I understand that unless otherwise limited by state or federal regulation, and except to the extent that action has been taken which was based on my consent, I may withdraw this consent at any time.

Authorization for Release of Information. Please sign your full name and date.

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