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

Applicant name

Address Line 1

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.

Town/city

County

Postcode

Telephone

Email address

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

Date of birth

Are you a member of one of the following organisations?

Adrenaline AlleyActive in Motion (A.I.M)BothYou must be a member of Adrenaline Alley and/or Active In Motion to apply

Do you have a disability or have any access or communication requirements you would like A.I.M and/or Adrenaline Alley to be made aware of?

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.

Forename

Surname

Relationship to applicant

Organisation (if applicable)

Work/Office Phone

Home Phone

Mobile Phone

Address Line 1

Town/City

Postcode

Section 2 - Request for support

Please describe why you would like and are in need of support to access counselling sessions through Active In Motion (you may wish to include information on your financial circumstances)

Have you received a bursary before? If so when?

If this application is not awarded will you be able to access wellbeing support any other way?

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.

Documents to Follow in Post

Yes

Bank Statement

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.

Declaration Approved

Yes

Contact Information