Eligibility Form

1. Personal Information

Full Name *

Phone *

Email *

Date of Birth *

2. Address Information:

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

3. Financial Information:

Are you currently receiving Universal Credit? *

Are you currently receiving House Benefit? *

Do you receive any financial support from the government?

Please Specify the details of financial support from the government? If any.

4. Referral Information:

Have you been referred to us by another organisation?

Organisation Name

Contact Person(If Applicable)

Phone/Email

5. Required Document Uploads:

Proof of Identity (e.g., Passport, Driving Licence) *

Drop your file here or click here to upload You can upload up to 1 files.

Proof of Address (e.g., Utility Bill, Bank Statement) *

Drop your file here or click here to upload You can upload up to 1 files.

Proof of Benefits (e.g., Universal Credit Statement, Housing Benefit Letter) *

Drop your file here or click here to upload You can upload up to 1 files.

6. Additional Information:

Why are you seeking therapy support? (Please briefly explain your current situation): *

Have you previously received therapy or mental health support? *

7. Declaration *

Note: If you do not receive benefits but feel you may still be entitled to our services, please email us at support@mhwfoundation.co.uk for further assistance.