Name * First Name Last Name Email * Phone * (###) ### #### Address * Have you had a chronic health condition for the past 3 months or longer? * Yes No Does your condition affect the functioning of your daily life? * Yes No Are you on a low wage, on benefits or a student with low income less than £10k? * Yes No Is your household income less than £20k per year? * Yes No Do you frequently worry about meeting basic needs? * Yes No Do you have financial savings? * Yes No Can you afford to take holidays? * Yes No Do you have expendable income (are you able to buy coffee out, dine out, go to the cinema, buy clothes and books)? * Yes No Thank you for your application. Our clinic is open on a Monday and Thursday and we can’t always rely outside of these times. Please be asaured we will be in touch.
