Counselling4Carers On-line Form – The Leonardo Trust

Counselling4Carers Form

Please fill in all the fields marked *

Agency Details
Agency Name*
Your Name*
Your Role*
Agency Address*
Postcode*
Tel No.*
Mobile No.*
Agency Email*
Enter Email Confirm Email
Carers details
Name*
Address*
Postcode*
Tel No.*
Mobile No.*
Email*
Enter Email Confirm Email
Date of Birth*
Date Format: MM slash DD slash YYYY
How long have they been a carer?*
Name of person cared for, their age and relationship to carer*
Information about the grant you are applying for
Has the carer received a grant from us before? If yes, please give details. This does not mean that we won’t be able to help them again.*
Please tell us how a course of counselling would help the carer?*
The trustees regret we are unable to reimburse costs already paid or anything that has been booked, contracted for or reserved prior to our agreement to fund/part-fund the cost. Many of the grants we award are under £300 and we may ask a carer to contribute towards the cost of an item.
Consent*
I agree to the privacy policy.
I understand that all information supplied on this application form will be kept strictly confidential and will only be used for the purpose of selection and administration. The information I have given in this application is, to the best of my knowledge, true and accurate. I accept that any false or misleading statements may be sufficient cause for rejecting an application. A copy of our Grant Making Policy is available on our website, www.leonardotrust.org or alternatively from our Broadstone office.

If you have any difficulties in completing this form or would like to discuss your application, please telephone 01202 698325 or email info@leonardotrust.org

Counselling4Carers Form

Agency Details

Carers details

Information about the grant you are applying for