Apply for Assistance

Complete the form below to apply for our assistance program. We review all applications promptly and will follow up by email.

Eligibility Requirements

Adult (18 or older)
Currently receiving active care or services
Experiencing financial hardship related to out-of-pocket costs
U.S. resident

Edit these requirements in Admin → Pages → Apply — Eligibility Requirements.

Your Information

First Name

Last Name

Email Address

Phone Number

Address

Street Address

Apartment, Suite, etc. (optional)

City

State

ZIP Code

Assistance Program Details

What are you applying for?

Briefly describe the help or service you are requesting.

Tell us about your current situation

Help us understand your circumstances and why you need assistance.

Number of people in your household

Amount requested (if applicable)

Leave blank if not requesting a specific dollar amount.

Anything else we should know?

Consent & Acknowledgment

I certify that the information provided is true and accurate to the best of my knowledge. I understand that Unity Grove may verify the information I have provided and that providing false information will disqualify my application. * I consent to being contacted by Unity Grove regarding my application and for follow-up purposes.

We will review your application and follow up by email.