Take a step towards better mental wellbeing : this form takes 2 minutes to complete and we promise to get in touch within 24 hours. It really is that simple to access our support !

Take a step towards better mental wellbeing : this form takes 2 minutes to complete and we promise to get in touch within 24 hours. It really is that simple to access our support !
Part A : Applicant details and contact consent
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Contact Number*
Please enter a valid phone number excluding country code.
Email Address*
example@example.com
By completing this form you agree we can contact you by phone, email or post to discuss your application, throughout the time we support you and at the end of our support to gather feedback on how we have helped you and how our service can be improved. You also agree that during the 12 weeks of our support, our suppliers are allowed to report to us on the frequency and type of activity you have undertaken.

YesNo
PART B - Do you meet our mental health criteria ?
We support those who are currently receiving support for a mental health issue from NHS Talking Therapy. When we discuss your support plan later you will need to provide evidence that you are receiving this NHS Talking Therapy support via the email or other confirmations they may have sent you. For now, simply indicate whether you are receiving support from NHS Talking Therapies.

YesNo
PART C - Your income will not determine whether we can support you, but can you indicate if your income is less than £35k per annum.
My income before income before tax is less than £35k per annum.

YesNo
Whether you receive benefits will not determine whether we can support you, but for our records can you confirm whether you receive any of the following benefits : Universal Credit, Housing Benefit, Working Tax Credits, Child Tax Credits, Income Support, Income based job seekers allowance, Pension Credit, Income based employment support allowance.

YesNo
Part D : Other declaration - it is important you read this declaration as it describes how you must take advice from a healthcare professional (GP or other suitable healthcare professional) if you have any health issues or other reasons that may influence your suitability to do your chosen activity.
We support people by providing free access to activities of their choice for a period of time that may help to further their mental wellbeing. This might be physical activity, music, art, crafts, learning or other hobbies that you choose. If you choose to answer YES to this question (Part D) you understand that if you enter into any exercise, hobby or activity programme in general it is your own choice and at your own risk of personal injury or harm to yourself or others and will seek appropriate advice from a GP or other medical professional if you have any doubts as to your ability or suitability to undertake the activity of your choice safely. By clicking YES to this question you are also agreeing that The Little Push 4 Good will be held harmless from any claims of negligence if injury or harm to yourself or others results from the activity you have chosen to pursue. Please email us on info@thelittlepush4good.org.uk if you do not understand this declaration and it requires further explanation.

YesNo
Please indicate here that all the information you have provided in this form is correct.

YesNo
Date

DayMonthYear
If you are unable to submit this form digitally, please email us on info@thelittlepush4good.org.uk to discuss our support or telephone us on 0780 1146105.
Thank you for contacting us. We will be in touch via email or phone within 24 hours to agree when we can talk with you to discuss a “little push” activity programme. We hope we can support you on your journey to better mental health.
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