Applying for carpets

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

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

How this will help their recovery or prevent relapse.

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

We have an agreement with Aldershot Carpet Services to provide basic fitted carpets for a bedroom and living room. The client can chose the colour. Occasionally the hall can be carpeted as well.

When the grant is agreed this will be confirmed on the Grant Award letter with the grant reference number. A copy will be emailed to Aldershot Carpet Services.

After you have received the Award letter, You or the client must then contact Aldershot Carpet Services to confirm details, please quote the grant number.

Exceptions can be made e.g. a family moving into a larger flat. If that is the case please explain that in the grant application or in email discussions.

It is possible to use other providers if there is a good reason. However, the items funded will have to be of an equivalent price and standard and the provider must accept BACS payments.

If rugs or other floor covering is required please apply through the general system.

Broadhurst operating area

Applying for carpets

If rugs or other floor covering is required please apply through the general system.

Broadhurst Welcome Home Community Ltd