Healed Healers Mental Health Services Scholarship Fund Application

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

What type of service are you seeking assistance for?

Please describe your need.

How long have you been experiencing this need?

Is this assistance request:

How frequently do you anticipate receiving services?

Estimated cost of services (per session):

Estimated total cost of services:

Name of provider or organization:

Provider contact information:

Have you already begun receiving services?

Why are you requesting financial assistance?

Approximate household monthly income:

Approximate household monthly living expenses:

Would you be open to receiving additional resources that may help strengthen your overall financial and emotional well-being?

Scholarship Fund Terms and Conditions

The Healed Healers Mental Health Services Scholarship Fund exists to help individuals access mental health and healing services when financial barriers would otherwise prevent them from receiving care.

Scholarship funds are made possible through donations received by Healed Healers. A portion of donations received by the ministry is designated toward this scholarship fund.

Because scholarship funding varies from month to month, awards are determined on a case-by-case basis and are dependent upon:

-Available scholarship funds
-Demonstrated financial need
-The nature and urgency of the request
-The cost and duration of services requested

Scholarships may be awarded as either full or partial assistance. Submission of an application does not guarantee funding.

Healed Healers reserves the right to verify provider information and may, when appropriate, remit scholarship funds directly to the service provider rather than to the applicant.

Applicant Certification:

Name

Date

Healed Healers Mental Health Services Scholarship Fund Application

Electronic Signature