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Community Wellness Fund Application — The Local Church

The Local Church's Community Wellness Fund provides financial assistance for medical and wellness needs — including counseling and therapy, hospital or clinic bills, prescriptions, rehabilitation, and other health-related expenses. If you're not sure whether your need qualifies, reach out anyway. We'd rather talk it through than have you go without.

🔒 Your privacy matters. This application is confidential and only reviewed by a small, trusted team. You will never be asked to prove hardship — we take people at their word.

About you

First name

Last name.

Best way to reach you

Best way to reach you
A
B
C

Email address

Phone number

Zip code

Helps us confirm you're in our service area.

Your need

What kind of need are you seeking help with?

What kind of need are you seeking help with?
A
B
C
D

Provider, practice, or service name

For example: a therapist, clinic, hospital, or pharmacy. Leave blank if you haven't identified one yet.

Insurance & financial context

Do you currently have health insurance?

Do you currently have health insurance?
A
B
C

Does your insurance cover the type of care you're seeking?

Does your insurance cover the type of care you're seeking?
A
B
C
D

Is there anything else about your financial situation you'd like us to know?

This helps us understand your need. There's no right or wrong answer — we take people at their word. You will never be asked to submit documentation or prove hardship.

Consent & next steps

By submitting this form, you're giving us permission to reach out to discuss your application and, if approved, to coordinate directly with your provider or service to cover approved expenses. Your information will not be shared beyond our Community Wellness Team without your explicit consent.

I understand and agree to be contacted by the Restoring Wholeness team.

I understand and agree to be contacted by the Restoring Wholeness team.
A

If approved, I give permission for funds to be paid directly to my provider or service on my behalf.

If approved, I give permission for funds to be paid directly to my provider or service on my behalf.
A

A little more

Are you connected with The Local Church?

Are you connected with The Local Church?
A
B
C

How did you hear about this program?