Headway Bristol Independent Living Fund Application Form

Headway Bristol Independent Living Fund Application Form

Applicant Details:
Mr Mrs Ms Other
Forenames:
Surname:
Date of Birth:
Age:
Sex: Male Female / Applicant Contact Information:
Address:
Postcode:
Tel No: Home:
Mobile:
About your brain injury
When did it happen?
What was the cause?
How does it affect your daily life? Mobility problems Difficulty in using hand/arm
Memory problems Concentration problems Difficulty with decision making
Communication difficulties Problems with mood e.g. feeling low, difficulty in controlling anger
Sensory issues e.g. visual or hearing problems
Please describe how it affects you:
Your accommodation:
If you are in the process of moving please Owner Occupied Private Tenancy Council Tenancy
give answers about your new accommodation
Housing Association
Do you live: On your own With a partner With your family With a friend
Other (please describe)
Professional Contact Information
Please give details of a professional person e.g. Social Worker or GP who we may contact about your brain injury
Name:
Position:
Address:
Postcode:
Tel No:
Tick here if you want us to respond to this person with regard to this application. / Carer/Helper Information
Please give details of anyone who has helped you to complete this form.
Name:
Address:
Postcode:
Tel No:
Tick here if you want us to respond to this person with regard to this application.
Purpose for which grant is sought and how it will help the applicant to maintain/improve his/her independence: If you can please attach details of item and how to purchase.
Total cost of item £
Please supply a written quotation / Applicant’s contribution £
(If any)
Has applicant applied to or received help for this purpose from any other source? Yes No
Statutory Help
Applied to Amount
received
Social services £
LA Housing Dept £
Local health authority £
DSS Social Fund £
Other: £ / Other Charitable Trusts
Please list Applied to Amount
received
£
£
£
£
£
Total received £
To Date / Total still required £
What is the applicant’s current level of savings/funds £
Please advise why the savings cannot be used to fund this item or service:
To whom should grant be paid
(Payments will only be made by online or by cheque directly to the supplier)
Do you currently receive services or support from Headway Bristol? Yes No
If no, how did you hear about this fund?
Declaration
I hereby give consent for Headway Bristol to contact the relevant professional whose details are given on page 1 of this form to verify the information provided on this form and to share relevant information with regard to my brain injury.
I declare that the information provided above is true and accurate and that the person requiring help is in genuine need of funds to help them live independently.
Applicant
Name:
Please print
Signed: Date:
If you are applying on behalf of the applicant please sign here:
Name:
Please print
Signed: Date:
Relationship to applicant:

DATA PROTECTION ACT 1998

The information that you give will be used by Headway Bristol to process the application to administer and manage the Independent Living Fund and all other services provided by the organisation. The information will be kept securely, and will be kept no longer than necessary. The information will not be disclosed or shared with anyone outside the organisation.

Please return your completed form, by post to:

Headway Bristol

Headway Centre

Frenchay Hospital

Frenchay Park Road

Bristol BS16 1EH

or by email to:

If you have any queries with regard to the completion of this form, please telephone Headway Bristol on 0117 340 3771 or email to the address above.