Applying for something else

Client Name

First Name

Last Name

Client Postcode

for us to confirm eligibility

Diagnosis of Mental illness

Diagnosis and treatment

Other relevant diagnoses

e.g. Autistic Spectrum Disorder or Disability

Medication for Mental Health (required)

list of medication and dosage if known

Who has been treating your client?

GP Surgery Team

CMHRS

Counselling

Therapy

Voluntary Sector Support Groups

Other

Reason for request

Use to which the award will be put How this will help their recovery or prevent relapse. Please note that we will not consider awards relating to either “hoarding” or “pets”.

Amount Requested

£

Breakdown of costs

The name of the supplier/organisation/person to be paid*

Organisation

Only a partner organisation can refer, we do not accept referrals from friends or family.

Organisation Contact

First Name

Last Name

Organisation contact email

My client understands that the information about them contained in this application form will be used and retained by Broadhurst in the ways explained in the Privacy Notice at the foot of this page

My client has consented to this application

The information contained in this application form is accurate to the best of my knowledge and belief

Our fundamental criteria remain the same –

Living in Rushmoor or the surrounding area as defined on the map on our website

Diagnosed with a significant mental illness

The grant must promote recovery and/or prevent deterioration in the client's mental health. Please note that we will not consider awards relating to either “hoarding” or “pets”.

Once your award has been agreed, you will receive a grant award letter, you or your client will then need to contact your supplier to arrange delivery.

Broadhurst Operating Area

Applying for something else

Broadhurst Welcome Home Community Ltd