Funding Application — Be Well Circle

1 Applicant Information

Full Name *

Date of Birth *

Phone Number *

Email Address

Street Address *

City *

State *

ZIP Code *

Preferred Method of Contact

Phone Email Text

2 Household Information

Number of People in Household *

Number of Dependents

Are you currently employed? *

3 Annual Household Income

Total Annual Household Income (before taxes) *

If comfortable, estimated annual income

Do you have health insurance? Has your premium gone up?

4 Type of Support Requested

Please select the service(s) you are requesting assistance for *

Holistic Health Services (yoga, meditation, energy healing, holistic primary care, acupuncture) Educational Programs or Workshops Virtual Wellness Programs In-Person Classes Other (please describe below)

Name of Service Provider (if known)

Estimated Total Cost of Service/Program

Amount of Funding Requested *

4B Practitioner Treatment Recommendation & Funding Request

This section is completed by your approved practitioner. Once you're matched, they'll work with you to build your treatment plan and submit this funding request on your behalf. Leave it blank if your practitioner will complete it separately.

Practitioner Name

Practice / Organization

Phone

Credentials / License / Certification

Recommended Service(s)

Proposed Treatment Plan

Type of Service(s)

Frequency of Sessions / Visits

Estimated Number of Sessions

Estimated Duration of Treatment Plan

Expected Goals and Outcomes

Cost of Treatment Plan

Cost Per Session / Visit

Number of Sessions

Additional Fees (if applicable)

Total Cost of Treatment Plan

Description of Additional Fees

Shared Financial Participation Practitioner Contribution (discount offered)

Flat Discount Amount

Percentage Discount

Total Practitioner Contribution

Client Contribution

Amount Client Has Agreed to Pay

Payment Plan (if applicable)

Amount Requested from Be Well Circle

Practitioner Statement

I certify that the information above is accurate and represents my professional recommendation for this applicant. I understand that funding decisions are made solely by Be Well Circle and are subject to available funding and program guidelines.

Practitioner Signature

Printed Name

Date

5 Statement of Need

Please describe your current circumstances and why you are seeking financial assistance. Include any relevant financial, personal, or health-related factors. *

6 Impact Statement

How do you believe receiving this support will impact your life, health, education, or overall wellbeing? *

7 Additional Information (Optional)

Is there anything else you would like the review committee to know?

8 Certification & Signature

I certify that the information provided in this application is true and accurate to the best of my knowledge. I understand that funding decisions are made at the discretion of Be Well Circle and are based on available funds and demonstrated need.

Full Name (as signature) *

Date *

Your application is confidential and will only be reviewed by the Be Well Circle board.
Questions? team@remedycharleston.com

Application Received

Thank you for reaching out. The Be Well Circle board will review your application and be in touch. We're honored you trusted us with your story.