BIPOC Mental Health Grant

Please read all instructions and requirements before proceeding to the form.

  • You must have a current PHW Collaborative Pledge on file.
  • The applicant must be a faith community.
  • The faith community must be predominantly of color/ BIPOC (Black and Brown, Indigenous, and People of Color).

If you need assistance completing the form, please don't hesitate to contact the Associate Director, Partners in Health and Wholeness, Mental Health Advocacy, Rev. Jessica Stokes jessica@ncchurches.org

Attention

  • You are not able to save and come back to the Pledge form.
  • We recommend you print this document to prepare your responses BEFORE entering them on this form.
  • We also highly recommend you save your answers on a separate document as you fill out the form so that you do not lose your responses if the form closes for any reason.
  • A copy of your pledge submission will be sent to you and your faith leader.
  • ONCE YOU HAVE SUCCESSFULLY SUBMITTED THE FORM, PLEASE CHECK TO MAKE SURE YOU HAVE RECEIVED A CONFIRMATION EMAIL
  • All applications that include a request for grant funds that require in-person gatherings or other activities that could be affected by the COVID-19 virus, must include a Plan B in case of a worsening of the virus and/or a tightening of restrictions. For example: if your grant request includes in-person gatherings in an enclosed space, and the virus worsens or restrictions tighten, what will you do instead? If your grant request includes funds for children in school, but schools close, what will you do instead? Including this information in the grant request will allow us to review in a timely manner and not hold up your application while we follow up with you.

Form Submission Guidelines

When filling out the form, please type every name out fully with no abbreviations including congregation names, health lead names, and faith leader names.

Example: St. Maria's United Methodist Church
NOT: St Marias UMC

As we continue to expand our network, we hope you will continue to include as much detail as possible in the PHW forms. We ask Health Leads to always answer the 5 W's: Who, What, When, Where, and Why?

* Items with this symbol are required information

General Information

Congregation
Mailing Address
Physical Address
Church Health Lead Contact Information
Faith Leader's Title and Contact Information

Details About Requested Funds

Example
"LivingWorks Faith" Suicide Prevention Training Class $166.62 per person (12)- $1999.44
Talkspace Therapy App vouchers 75.00 (50)- $3,750
Honorarium for Mental Health Speakers (3) at $600.00 each (lodging, gas, food)- $1800

*your costs may vary