Counselling / Therapy Request Form

Counselling / Therapy 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.Format: (000) 000-00000.
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.

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Counselling and Therapy
Why have you decided that now is the time to seek counselling or therapy?
What difference would this make to you at this time?
How do you hope this kind of support will help you? (tick all that apply)
Do you have a preference for either in-person sessions or virtual sessions?
Are you having any other therapy/counselling or due to have any? Please explain
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?
Are you happy for us to share your information with counsellors or therapists so that we can get you the right support?
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:

Counselling / Therapy Support Request Form

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 .