Name of Client:
Date of Birth:
Presenting Problem:
Is the client working? (Details)
Accommodation details (own property, rent, etc):
Details of Any Benefits Weekly/Monthly :
Details of other income Weekly/Monthly :
Details of savings :
In your opinion as therapist, once the subsidised therapy has ended will treatments be complete or if not, will you continue to offer further low-cost treatments?
Minors If your client is a minor please read the information about treating minors in the member’s area.
Proposed Costs Proposed contribution per session the client can afford: £
Your usual therapy cost per session : £
How many sessions does the client need (if unknown please provide a rough estimate) :
Amount outstanding per treatment :
Discount required from Therapist per treatment :
The amount AAC will contribute per treatment :
Total outstanding funds required :
Sessions AAC can provide :
AAC total payout over the sessions :
Therapist's Name:
Email address:
Membership Number:
Telephone Number:
I confirm that I have explained the limitations of the therapy subsidy to my client and if the application is successful AAC will only provide subsidised funding upto a total of £120 per client.
Signature:
Date:
