Shining Star Application for Children’s Mental Health Services

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The mission of the One Lamb initiative is to nurture and embrace mental wellness in a faithful community of connection and support. A portion of funds raised for One Lamb will be available to help members of our community with the exorbitant cost of mental health and addiction treatment.

Please complete this form as accurately as possible. Once submitted, all information will be kept strictly confidential. We recognize that timing is critical and we will make every effort to expedite the review process.

Application General Information

Full name, age, and address of individual in need:

Your name and relationship to the individual in need:

Your Email:

Contact Number for Applicant or Applicant's Guardian:

Name and address of accredited program/treatment center/PHP/IOP/therapeutic school or counseling service:

Contact person and phone number for the above:

Anticipated start date:

Anticipated length of treatment:

Type of Treatment Needed:

Is this the first time seeking treatment? If no, please briefly explain:

Please provide a general description of mental health and financial need:

Should your application be accepted, do you agree that this is a love offering with a desired emphasis to "pay it forward". This could mean reimbursing the fund at a later date or using your individual gifts, talents, and/or experience to assist this ministry or someone in need sometime in the future.

Yes

Please provide the monetary amount of financial need for this treatment:

Any additional information you'd like to share:

Please check which organization with which the child is affiliated:

PALS

Agape

Prison Ministry

Opt-In

YES, The undersigned understands and agrees that this application is solely for children under the age of 18. Information provided on this application may be confidentially shared with The Shining Star Review committee for purposes of consideration of this application. The Shining Star review committee reserves the right to confirm the acceptance of the applicant or applicant's minor in the designated treatment provider disclosed in this application. One Lamb Initiative and Shining Star fund distributes love offerings directly to the service providers and in compliance with PRUMC's 501(c)3 status.

Opt-In

Yes, I acknowledge that this scholarship is a gift given in love, with no expectation of repayment. The funds are provided in memory of Gayle Cummings, a devoted advocate for children. Please consider honoring this gift by paying it forward by sharing kindness, compassion, and love with those around you.

Digital Signature of Applicant’s Parent/Guardian:

Shining Star Application for Children’s Mental Health Services

Application General Information

Contact Info