Application for Family Support
Thanks to the generosity of our fundraisers and supporters, Changing Minds with PickUp a Penny is offering five families in the North East of England fully funded access toour pioneering, person-centered, integrative therapies. This initiative, led by Dr SaraYoung and her experienced team, is designed to support children and young peoplestruggling with their mental health, emotional well-being, or physical health.This unique opportunity is intended for families who are open to working collaborativelywith our team and willing to engage in recommended therapies and approaches to helptheir child thrive.If this sounds like the right fit for your family, we’d love to hear from you.
Name of parent/guardian of child or young person
First Name
Last Name
Your relationship with the nominated child/young person?
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Child or Young Person's Name
First Name
Last Name
Child or Young Person's Postcode
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age of child or young person
Year in school
Other children or dependents of the same household
Back
Next
Please describe the challenges your child is currently facing.
These can be diagnosed or undiagnosed challenges. We want to better understand the quality of life of both you and your family.
Back
Next
Tell us the story of how these challenges began to present themselves. Please be as detailed as you feel comfortable sharing.
Please understand that we are here to help. The more you can share, the easier it will be for us to help.
Back
Next
In your own words, how do you feel this initiative could benefit your child and your wider family?
Back
Next
Eligibility & Commitment Checklist
The nominated child/young person lives in North East England
Yes, we live in North East England
No, we do not live in North East England. (We are limited by our reach in the North East of England, but we can try to connect you to other services available in your location)
The nominated child is currently struggling with physical wellbeing, mental, or emotional health.
Yes
No
The family of the nominated child/young person are open to working in partnership with the team, including undertaking suggested therapies or support for parents/carers and whole families.
Yes, we are committed to this process
No, you will need to secure this commitment as I am nominating a child that I am not a parent or guardian for.
The family of the nominated child/young person understand that anonymised feedback and outcomes may be shared to help secure funding and support other families, including details collected on this form.
Yes, we understand
No, you will need to secure permission from them as I am merely nominating them.
Submit
Should be Empty: