Details of medical condition and impact on your/their life*

Tell us:

• What illness or disability they have.

• How long they have had it.

• What treatment or support they are getting.

• How it affects their everyday life.

• What they now struggle to do.

• How it affects their mental health or wellbeing (if relevant).

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Is it likely that the applicant will be able to work?*

Tell us:

• Are you/they working now?

• If not, why not?

• Do you/they expect to go back to work?

• If yes, when?

If you/they don't know when you/they can return to work, just say this.

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Background / Brief History of Applicant*

Tell us a little about yourself.

For example:

• Who you/they live with.

• Whether you/they worked before becoming ill.

• How life has changed since you/they became ill or disabled.

• Anything else that helps explain your/their situation.

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Current Circumstances

Tell us what life is like now.

You could include:

• Who you/they live with.

• Money worries.

• Problems you/they are facing.

• Help you/they already receive from family or professionals.

• Anything making life more difficult.

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Help Requested

Tell us:

• What you/they are asking for.

• How much it costs.

• Why you/they need it.

• Whether anyone else is helping to pay for it.

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The Impact This Will Have?

Explain what difference the grant will make.

For example:

• Will it make everyday life easier?

• Will it improve your/their health or wellbeing?

• Will it reduce stress or worry?

• Will it help you/them stay independent?

• Will it help your/their family?

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Wider Support In Place

Tell us about any other support they already have.

For example:

• Family or friends.

• GP, hospital or community nurses.

• Social worker or support worker.

• Charity or community support.

• Benefits they receive.

If you/they don't have much support, tell us that too.