Counselling4Carers On-line Form – The Leonardo Trust

Counselling4Carers Form

Please fill in all the fields marked *

Agency Details
Your Name & Job Title*
Agency Address*
Postcode*
Tel No.*
Agency Email*
Enter Email Confirm Email
Carers details
Name*
How long have they been a carer?*
Address*
Postcode*
Tel No.*
Email*
Enter Email Confirm Email
Date of Birth*
DD slash MM slash YYYY
Who lives with the carer?*
Does the carer or anyone else in their household work? Please describe*
Please tell us about the Carers financial circumstances
Benefits they receive (Please enclose evidence)*
Household Income (Either per month or P.A. Please include all members of their household)*
Total savings*
About the person cared for
Name of person cared for*
Relationship to carer*
Please describe their illness or disability*
Age*
How would a course of counselling help the carer?*
When explaining how a course of counselling would help a client, please explain how day-to-day life is impacted, what they hope to gain from counselling and what would the client like to discuss in the sessions.
Consent*
I agree to the privacy policy.
I understand that all information supplied on this application form will be kept strictly confidential and will only be used for the purpose of eligibility and administration. The information I have given in this application is, to the best of my knowledge, true and accurate. I accept that any false or misleading statements may be sufficient cause for rejecting an application. A copy of our Grant Making Policy is available on our website, www.leonardotrust.org or alternatively from our Broadstone office.

If you have any difficulties in completing this form or would like to discuss your application, please telephone 01202 698325 or email info@leonardotrust.org

Counselling4Carers Form

Agency Details

Carers details

Please tell us about the Carers financial circumstances

About the person cared for