Malden Overcoming Addiction (MOA) Scholarship Application

DISCLAIMER:  The foregoing application is for purposes of connecting the applicant with available resources and will remain confidential.

I understand no promises have been made to me relative to treatment, Recovery Coaching, case management or supportive services.  I also understand that the role of Malden Overcoming Addiction (MOA), is only to connect individuals with addiction support and recovery services.  MOA does not offer or provide any type of medical, clinical or mental health treatment or services.  I also acknowledge that I am participating voluntarily in using the services offered.

*Due to the current availability of resources, the application process is limited to Malden residents only.

*Please fill out this MOA Scholarship Application Form completely as it allows MOA to properly assess your needs.

**If you are chosen to be interviewed, you will be required to formally sign this application at the interview in order to proceed further in the application process.

Name *
Name
Gender
Phone
Phone
Address
Address
Date of Birth
Date of Birth
Are you or could you be pregnant?
This will not affect your application it will only help with placement. Please check the appropriate response below.
Have you previously applied for the MOA Scholarship within the past three months?
Are you willing to relocate for a minimum of 30 days?
Are you willing to meet with an MOA Recovery Coach to discuss how your recovery is progressing and establish your continued need for a scholarship?
Are you willing to go to detox and 30 days of treatment before entering a recovery house?