In order to receive a scholarship from DMMF you must go to detox if medically necessary and then spend 2-4 weeks in a holding. If you do not need a detox you must be willing to complete 2-4 weeks in a holding to be eligible. If you are applying from detox or holding remember to leave a contact name and their phone number as well as signing a release for DMMF committee members.

What are your goals? *

If yes, what insurance type?

Name: *

Do you have children? *

Yes

No

Have you ever been to treatment? *

Yes

No

If yes, who has custody/guardianship?

Email: *

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How can we help? *

If need be, are you willing to relocate temporarily and/or go to sober living? *

Yes

No

Please submit a state case worker's information if currently in treatment.

Are you willing to commit to 6 months of treatment

yes

no

Thank you for contacting us! If needed, you will hear back within 48-72 hours.

Where are you currently residing (detox, holding, home, etc.) *

Date of Birth *

Marital status: *

Single

Married

Divorced

Widowed

DENNIS MESSING

MEMORIAL

FOUNDATION

Dennis Messing Memorial Foundation.