Eligibility Form

Home Eligibility Form

Eligibility Form for Funded Therapy Sessions

We provide fully funded therapy sessions for individuals who may not be able to afford private therapy. Please complete this form and upload the required documents to determine your eligibility. All information provided will be kept strictly confidential.

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1. Personal Information

Your Name

2. Address Information:

Your Address

3. Financial Information:

Are you currently receiving Universal Credit?
Are you currently receiving House Benefit?
Do you receive any financial support from the government?

4. Referral Information:

Have you been referred to us by another organisation?

5. Required Document Uploads:

Click or drag files to this area to upload. You can upload up to 4 files.
Click or drag files to this area to upload. You can upload up to 4 files.
Click or drag files to this area to upload. You can upload up to 4 files.

6. Additional Information:

Have you previously received therapy or mental health support?
7. Declaration *

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