Residental wellbeing application form

Please complete and submit the form below.

Surname

Forenames

Address

Contact Number

Email Address

Confirm Email Address

Postcode

D.O.B.

Force (if retired, previous force)

Collar Number

Next of Kin Name

Next of Kin Contact Number

Relationship

Residential Wellbeing Criteria (please tick which apply)

Currently off sick from work

Experiencing a life changing event e.g. bereavement, relationship break down

Under a counselling service

Acute or chronic mental health condition, please provide details below

Acute or chronic medical condition, please provide details below

Terms

All applications will be assessed by the Clinical Services Team, applicant will be informed of decision and available dates within 7 to 10 working days of receipt of your application.
Member will be informed if further information is required.
Residential wellbeing breaks must be taken within 6 months of application.
Residential wellbeing breaks are individual breaks and are not open to partners, spouses, or dependents.
You will not be eligible to access a residential wellbeing break if you have received one within the past 2 years.

Please provide details to demonstrate you meet the criteria you selected

Have you, or are you, receiving any previous or ongoing treatments in relation to the above?

Please indicate which of the following applies to you:

Currently in work

Recuperative duties

Restricted duties

Sick leave

Do you have limited mobility, i.e. use of a wheelchair/walking aids? (If yes, please provide details)

YesNo

Limited mobility details

Do you have any allergies? (If yes, please provide details)

YesNo

Allergy details

Do you have any dietary requirements? (If yes, please provide details)

YesNo

Dietary requirements details

Do you require an additional carer to attend with you during your stay? (If yes, please provide their details below)

YesNo

Carer Name

Carer Contact Number

I can confirm I am a member of The Ben Fund

Personal information which you supply to us may be used in several different ways, for example: To make admission and clinical decisions; for audit and statistical analysis; for fraud prevention.

The Ben Fund is committed to protecting your privacy and security. Whenever you provide personal information, we will treat that information in accordance with UK Data Protection legislation. Further details can be found in our Privacy Policy which can be found on our website at: https://www.thebenfund.co.uk/privacy-policy.

I understand that all personal information on this form will be confidential to the professional and administrative staff of The Ben Fund and no personal information or clinical reports will be shared without my express consent unless required by law.

I agree to The Ben Fund contacting me using the details I have provided.

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