Headway Emergency Fund - Application Form

Use this form to apply for a grant. Please provide us with as much information as possible, and ensure you complete the form to the end.

As a UK-based charity, Headway has limited funds. In order to support as many people as possible, we are unable to provide grants to applicants with savings of over £1,000, or brain injured parties who do not normally reside in the UK.

Due to increasing and unprecedented demand for support from the Emergency Fund, applications are currently only being considered for those with transport and accommodation needs to visit loved ones in acute care following a brain injury diagnosis.

Please note, rehabilitation wards and units are not classed as acute care. However, if they are in the very early stages of rehabilitation (needing regular nurse input and are not medically stable) your application will be considered.

While regretful, we are implementing this temporary measure to ensure the sustainability of this vital support service. In the meantime, we continue to seek additional funding for this programme.

Please ensure you review the type of support the Emergency Fund can and cannot provide before making an application.

The form will appear only if qualifying conditions are met.

Qualifying questions

Date of birth of the brain injured party (the Emergency Fund is only available where the injured party is 18 years of age or older)

Application for individual under 18

The Headway Emergency Fund is available to people with brain injury who are 18 years of age and older. Please contact the Child Brain Injury Trust for further information. Visit childbraininjurytrust.org.uk to find out more.

Does the family requiring help have savings of more than £1,000? (If 'Yes', you will not qualify for an Emergency Fund grant)

YesNo

Is the brain injured party a UK resident? (If 'No', you will not qualify for an Emergency Fund grant)

YesNo

Is the person who sustained the brain injury currently in hospital or rehabilitation? (If 'No', you will usually not qualify for an Emergency Fund grant, but you can complete an application as occasional exceptions may be made)

YesNo

Age

Age Calc

Your application does not meet the qualifying criteria. Please contact the Headway helpline on 0808 800 2244 or helpline@headway.org.uk to discuss further support that may be available.

About the person who has sustained a brain injury

First Name

Last Name

Address Line 1

Address Line 2

City

Postal Code

Country

Cause of brain injury

Other cause

Date of Brain Injury

Hospital

Name of Hospital

Address Line 1

Address Line 2

City

Postal Code

Country

Ward

Consultant Name

As a UK-based charity, Headway has limited funds. In order to support as many people as possible, we are unable to provide grants to applicants with savings of over £1,000, or brain injured parties who do not normally reside in the UK.

We can only provide funding for travel, parking and accommodation costs for visiting a loved one in acute care.

About the person who will receive the grant

Please enter details about the person who will receive the grant

First Name

Last Name

Address Line 1

Address Line 2

City

Postal Code

Country

Mobile phone number

We will contact the person needing help on this number to discuss the application

Home phone number

If possible, please provide an alternative number to help us get in touch

Email address

Relationship to the person with the brain injury

Are you supporting someone to complete this application?

YesNo

As a UK-based charity, Headway has limited funds. In order to support as many people as possible, we are unable to provide grants to applicants with savings of over £1,000, or brain injured parties who do not normally reside in the UK.

We can only provide funding for travel, parking and accommodation costs for visiting a loved one in acute care.

Applying on behalf of someone else

You indicated that you are applying for this grant on behalf of someone else. Please enter your details here.

Are you

A professional/clinician applying on behalf of someone elseAn individual applying on behalf of someone else

First Name

Last Name

Job title

Employing organisation

Address Line 1

Address Line 2

City

Postal Code

Country

Work phone number

Mobile phone number

Home phone number

Email Address

Relationship to the person needing help

As a UK-based charity, Headway has limited funds. In order to support as many people as possible, we are unable to provide grants to applicants with savings of over £1,000, or brain injured parties who do not normally reside in the UK.

We can only provide funding for travel, parking and accommodation costs for visiting a loved one in acute care.

Reason for applying for emergency funding

Please explain why the grant is required. This should include information about the financial situation.

Please provide a breakdown of how the grant will be spent

If you are applying for accommodation, please tell us:
Do you have a preferred accommodation? Please provide the name and address.
Do you have any accessibility requirements?
What is your mode of travel to the accommodation?
Will anyone else in the family be staying at the accommodation e.g. children?

If you travel by car, please tell us:
The engine size and fuel type of the car you use the most.
For example, electric, 1.2 litre petrol, diesel or hybrid.
How much parking is per day or per week.
How many times you travel per week.

If you travel by bus, please tell us:
How much the return journey is per day or per week.
How many times per week you travel.
Which company provides your bus service.

If you travel by train, please tell us:
Which station you depart from and which station you arrive at.
How many times per week you travel.
How much it costs you for a return journey.
If you have any railcards or passes, please state which ones you have.

Doctor/Nurse	Headway Helpline
Headway Website	Hospital Information
Local Headway Group/Branch	Search Engine
Social Worker	Word of Mouth
Other