Appeal Against Rejected Counselling Application

My Details

Name

Last

Address (street)

Postcode

Email

Telephone

Appeal Consent

I would like support from DisabilityPlus to appeal the decision for the rejection of my application for specialist counselling.

The role of DisabilityPlus is to assist me with any additional information that would support me in appealing the rejection of funding for my specialist counselling.

I understand that any appeal will not be automatically approved.

By signing this form, I agree I have not been solicited or pressured by disabilityPlus into making an appeal against the rejection of my funding for counselling.

I understand that the information within any letter or document will be shared with my doctor & subsequently shared with a funding panel to determine my suitability for an appeal.

By signing this form I give DisabilityPlus consent to help me in appealing the decision of this rejection of funding.

Consent

Who is giving consent?

Client (Myself)

Carer

Client Authorisation

If this is not possible due to disability please ask your carer to sign in the section below.

Date

Signature

Clear

Authorised Carer Authorisation

Only to be completed if the client cannot write a signature.

Carer Name

Carer Relationship to Client?

Date

Signature

Clear