Family Assistance Fund Application

The Family House asks for $40/room/night. If you’d like to request a reduced rate, please fill out this application.

Please request a referral form from the medical center providing treatment before submitting this application.
If you are a patient staying at the Family House for outpatient treatment, do you have Medicaid? If yes, we may be able to bill your stay to your Medicaid Insurance. Please call 336-793-2822 to proceed.

First and Last Name *

Street Address *

City, State, Zip Code *

Phone Number *

Relationship to Patient *

Employer Name *

Employer Address *

Number of persons in your household *

Sources of income: Monthly wages/self-employment income *

Sources of income: Monthly social security/disability *

Sources of income: Monthly public assistance *

Sources of income: Monthly unemployment/worker's compensation *

Sources of income: Monthly alimony or child support *

Sources of income: Other (pension, dividends, interest, rent) *

Total monthly income for family: *

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