Grant Application

We are pleased you are taking the time to complete this form. Before completing, please familiarize yourself with all the questions to ensure you don’t repeat answers and that you meet all the necessary requirements.

GENERAL INFORMATION

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1. Organization Name: *This question is required.

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2. Key Contact: *This question is required.

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3. Email Address: *This question is required. This question requires a valid email address.

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4. Phone Number: *This question is required.

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5. Website: *This question is required.

DESCRIPTION OF ORGANIZATION

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7. Mission Statement: *This question is required.

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8. Number of Employees: *This question is required. This question requires a valid number format.

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9. Founding Year: *This question is required. This question requires a valid number format.

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10. Does your organization promote a specific religious belief and/or require beneficiaries to belong to a specific religion to benefit from our services? If so, please describe below: *This question is required.

GEOGRAPHICAL AREA OF OPERATION

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11. Headquarter Location:
*This question is required.

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12. Physical / Satellite Locations: *This question is required.

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13. Geographic Reach (Local, National or International): *This question is required.

DESCRIPTION OF SERVICES

Please briefly describe the mental health offerings that your organization addresses in any/all of the following areas:

Feel free to quote any statistics to help explain. Use bullet points where possible and a maximum of 400 words

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14. Treatment *This question is required.

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15. Research *This question is required.

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16. Prevention *This question is required.

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17. Education *This question is required.

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18. Additional services offered: *This question is required.

GRANT UTILIZATION STRATEGY & QUALIFICATIONS

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20. Please briefly describe your proposed project with a grant of this size. Describe and quantify the expected impact.

Use bullet points where possible and a maximum of 600 words *This question is required.

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21. Please specify if your proposed project is a new approach or scaling up an existing one. *This question is required.

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22. Explain a proposed budget for how the grant money will be used. *This question is required.

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23. Please state roughly what percentage (%) of your organization's overall income a grant of this size would represent. *This question is required. This question requires a valid percent format.

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24. For every dollar donated, please indicate how many cents are attributed to your overall mission versus how much is used for overhead?

Please provide the total amounts and the actual percentage in your response. *This question is required.

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25. If you do not receive the grant requested here, how will your project be impacted? *This question is required.

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26. To help us understand the full impact of our grants, please share whether our funding will be used by your organization to apply for any Federal, State, or private matching grants. *This question is required.

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27. What is your biggest organizational challenge? How are you working to address this challenge?

Consider the skills, the influence, the funding limits, organizational ability to grow, access, engagement, other. Use a maximum of 200 words. *This question is required.

SUPPORTING DOCUMENTS

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28. Please confirm if you have the following. If so, please provide copies of the respective documents.

Leadership Organizational Chart and Biographies of Leadership team
Annual report and audited financials for the last 2 years
Diversity, Equity & Inclusion Policy
Current Strategic Plan / Action Plan for your Organization

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Grant Application