Stage 1 Application form

Part A : Applicant details and consent

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityCounty

Postcode

Contact Number*

Please enter a valid phone number.

Email Address*

example@example.com

By applying for our support you agree we can contact you by phone, email or post to discuss your application, throughout the time you are using the grant and at the end of the grant to gather feedback on how we have helped you and how our service can be improved.

YesNo

PART B - Do you meet our mental health criteria ?

We aim to help those currently receiving support for a mental health issue from NHS TalkingTherapy or a supplier of Talking Therapy Services supporting the NHS. When we discuss your support plan later you will need to provide evidence that you are receiving this NHS support via the email or other confirmation they have sent you and other consents depending on the activity you wish to pursue.For now, simply indicate whether you are receiving support from NHS talking therapies or similar NHS provided service.

YesNo

PART C - Do you meet our income criteria for support ?

We have limited funds and therefore try to help those in greater financial need of our support.Please indicate that your income before tax is less than £35k per annum.

YesNo

At a later stage you will need to provide us with recent (last 6 months) salary information or yourmost recent tax return if you are self employed. The information must include your full name. Alternatively you might be receiving 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). Are you receiving any of the above benefits.

YesNo

You will later on need to provide a copy to us of the relevant benefits you receive - this must be your latest benefits award or a letter confirming your benefit entitlement (dated within the last 6 months, and clearly stating your name and address).

Please note you do not have to be receiving benefits and we will be able to support you if your income is less than £35k pa.

Part D : Other declaration

You may be choosing with our support to undertake an activity of your choice. This may be physical activity of some sort (or other hobbies - music, art, learning etc). Through signing this declaration you understand that if you enter into any exercise or activity programme it is at your own risk and will seek appropriate advice from a GP or other medical professional if there are any doubts as to your ability to undertake the activity of your choice.

YesNo

Please indicate here that the information you have provided above is correct.

YesNo

Date

If you are unable to submit this form digitally, please email a printed version (available on our website : www.thelittlepush4good.org.uk) to info@thelittlepush4good.org.uk or alternatively post to The Little Push 4 Good, 2 Fossview Close, Strensall, York, YO325BL.

Thank you for contacting us. We will be in touch via email or phone within 48 hours to confirm
whether we can support you and 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.