Follow the steps to complete your application online.

1. Press the ‘Get Form’ button to initiate the access to the application form and open it in your preferred editing tool.
2. Fill out the applicant information section. Provide your name (first, middle initial, last), date of birth, age, address, telephone number, cell phone number, social security number (optional), county, city, state, ZIP code, email address, and preferred method of receiving documentation (email, mail, or specify another option).
3. Complete the demographic information. Indicate your gender, marital status, military service history, race, tribal affiliation, education level, previous substance disorder treatment experience, living environment, and the number of children under 18.
4. Proceed to income verification. Report your annual household income as from your last tax return, household size, income from employment over the last 90 days, and employment status along with your position and current employer.
5. Continue with the income verification section by detailing any other sources of income and assets. Specify amounts as necessary.
6. Answer health care coverage questions. Indicate if you have Medicaid or Medicare coverage, include any relevant numbers, and provide details of any third-party insurance if applicable.
7. Describe your present needs in detail, including current symptoms and their severity. Be thorough to ensure your needs are understood.
8. Affix your signature to confirm the accuracy of the information provided and to attest that you meet the income criteria and do not have sufficient coverage.
9. The provider must also sign and affirm the individual's need for services, confirming they have verified the applicant's information.
10. After completing the form, save your changes, download, print, or share the application as needed. Be sure to keep a copy for your records.

Start filling out your application online today to access the essential services you need.