Declaration and Consent:
I declare that the information given on this form and with this application is to the best of my knowledge true and correct. I fully understand and agree that if any of the information which I have given is false this application will automatically be rejected and may jeopardize any future assistance with WLCC. I do not hold West Lincoln Community Care legally responsible for any counselling given by a third party provider. I grant consent to West Lincoln Community Care to share with my appointed counsellor, my contact information for the purpose of making contact and determining eligibility. I also grant my consent to my counsellor to use and disclose my personal information for these purposes.