VR therapies - financial support fund

Please complete this form if you would like to apply for discounted sessions through our support fund.
Funding is decided on an individual basis depending on the level of need.
Please be honest. We want to help as many people as possible and if you are able to pay a small amount, even if only a few pound, this keeps the funding pot available for more people.
If you need assistance filling out the form, please contact us at info@vrtherapies.co.uk or call us on 01604 622402.
Funding will be sent as a gift voucher e.g. 25%, 50%, 75% discount etc.
We aim to respond to all applications within 5 business days.
All information is kept secure and confidential.

Please send us an email at info@vrtherapies.co.uk if you do not receive a response within 5 business days

1. Name *

2. Email
*

3. Telephone number

4. Location (town/city)

5. Are you applying for this fund for yourself or on behalf of another person? This can be for an adult or child.

Myself
Another person
Other (please specify):

Date of Birth (for the funded individual) *

Eligibility

In this section we will ask questions about any problems you currently have with physical or mental health as well as any benefits you receive. If you are filling this form out for someone else, please answer on behalf of the funded individual

Please list any disabilities, medical conditions, special needs, mental health conditions, injuries or any other problems associated with physical or mental health.

6. If you receive benefits, please tick which one(s).

7. We know that many people slip through the net and may not qualify for benefits due to a multitude a reasons e.g. they are still awaiting assessment, or earn a tiny amount above the threshold. If you are facing financial hardship, please explain your situation so we can better understand how we may be able to help you.

VR therapies - financial support fund

1. Name *

2. Email
*

3. Telephone number

4. Location (town/city)

5. Are you applying for this fund for yourself or on behalf of another person? This can be for an adult or child.

Date of Birth (for the funded individual) *

Please list any disabilities, medical conditions, special needs, mental health conditions, injuries or any other problems associated with physical or mental health.

6. If you receive benefits, please tick which one(s).

8. Which room would you like to book?

9. Please provide any additional information you think would be helpful for us to know.

1. Name *

2. Email *

3. Telephone number

4. Location (town/city)

5. Are you applying for this fund for yourself or on behalf of another person? This can be for an adult or child.

Date of Birth (for the funded individual) *

Please list any disabilities, medical conditions, special needs, mental health conditions, injuries or any other problems associated with physical or mental health.

6. If you receive benefits, please tick which one(s).

8. Which room would you like to book?

9. Please provide any additional information you think would be helpful for us to know.

2. Email
*