Support Request Form

Support Request Form

Never worry about asking for help!
At Harry's Pals we provide support to parents of severely ill and disabled children diagnosed in the past five years. We understand that every family's situation is unique and want to ensure we can provide the best support. We will try our best to allocate services based on availability and need, so please give us as much information as you can (making sure to fill in each field) to help us consider your request. Everything will be treated in confidence
Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

Town/cityCounty

Post Code
How did you find out about Harry's Pals?*
How old is your child with the illness or disability?*
What is you child's diagnosis? or if your child doesn't yet have a diagnosis please describe their symptoms or health concerns as best as you can *
When did you receive this diagnosis?*
Please can you provide evidence of your childs diagnosis such as an up to date consultants letter, if not why not?*
Please upload evidence of your child's disability or illness (such as a consultants letter). This information will be kept and stored compliant with GDPR guidelines and will be treated in strictest confidence.*

Cancelof
What type of support would you like?*

Counselling or therapyA short break awayBoth
Short Breaks
Why are you applying for a break away? How would this benefit your family? Some ideas to consider: What difference would a short break make to you and your family at this time?*
When is the last time you went away?*
Do you have any holidays planned this year? Could you get away without our support?*
Can you tell me about any accessibility needs? For example do you need a profiling bed, hoists etc?*
How far can you travel? *
Are there any dates in which you cannot go?*
Who would you take? Please write all names including ages of children.*
Name

First NameLast Name
Email
example@example.com
Counselling and Therapy
Why would you like Counselling or Therapy? What difference would this make to you at this time?*
Do you have a preference for either in-person sessions or virtual sessions?*
Is self-funding for your required support not an option? Can you explain why this isn't possible at this time?*
Please can you let us know if you are in receipt of universal credit, child tax credit, and income based job seekers allowance. Can you also provide evidence of your most recent benefit entitlement if asked?*
*You can still apply if you don’t receive any benefits but we will need to understand your current financial situation
If you are not in receipt of benefits then we may need to gain a referral from a healthcare professional or hospice that understands your family situation before we can support you. Please leave their details below .

This might be a Physio, OT, Teacher, Social Worker etc..
Name

First NameLast Name
Position
Email
example@example.com
Would you be happy to share your feedback/photos to help us raise awareness of our services and to fundraise to help more families?*

YesNoYes but anonymously
Are you happy for us to share your information with holiday providers and counsellors or therapists so that we can get you the right support?*

YesNo
I blanks* confirm that the above information is true and complete to the best of my knowledge. I also confirm that I have read Harry's Pals criteria of support and believe I meet this criteria in accepting the requested support. Signature*
Is there anything else that you would like to tell us or that we should consider?
Should be Empty:

Support Request Form

Short Breaks

Counselling and Therapy

If you are not in receipt of benefits then we may need to gain a referral from a healthcare professional or hospice that understands your family situation before we can support you. Please leave their details below .