John Chard-Young Legacy Fund - application for counselling sessions

Active In Motion (A.I.M) Health & Wellness Centre Counselling sessions – sessions will be delivered by qualified counsellors committed to helping you improve your mental health and wellbeing through talking therapies. This can be taken up as 12 sessions and must be used within a six-month period. Extensions may be applied for at the discretion of the fund-holder. 

Section 1 - Contact details

Person applying for counselling sessions


This should be the address of the organisation. If the organisation doesn't have an independent location you can use the contact details of the primary contact.





The telephone number and email address should be one at which the organisation is easily contacted, especially during office hours


You must be a member of Adrenaline Alley and/or Active In Motion to apply
You must be a member of Adrenaline Alley and/or Active in Motion to apply to this fund. 
This fund is open to active members of Adrenaline Alley and Active In Motion, to qualify as an active member you will need to meet either of the following requirements:
  • Attended at least 2 Adrenaline Alley sessions within a 2 month period
  • Attended at least 4 AIM sessions within a 2 month period


If you are helping someone to apply, please provide your details:
If the individual applying for support is under the age of 16, please provide details of a parent/carer here.











Section 2 - Request for support



Have you contacted your GP or community organisations to access support?
Section 3 - Supporting documents and Declaration
Supporting Documents
Please provide a recent copy of your bank statement with this application.


Declaration
I confirm that I meet the eligibility criteria listed in the guidance notes to apply to this fund. I give permission to Northamptonshire Community Foundation to record the information in this form electronically for the purpose of grant management. I give permission for Northamptonshire Community Foundation to contact Adrenaline Alley and Active In Motion to confirm and share information about my application. 

Contact Information