You have supplied the following Details Title: Mr. Mrs. Miss Ms. Dr. Mobile Number: First Name: Work Number: Last Name Home Number: E-mail: Date of Birth: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. January February March April May June July August September October November December 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990   How did you hear of LACAP? Yahoo! search Google search GP Referral Other Referral Word-of-Mouth   Do you have a partner? Yes No Is your partner earning over £20,000 per year? Is your partner earning over £10,00 per year? Is this application something that you cannot discuss with your partner?   Please let us know the following: Are you in full-time education? Are you in part-time education? Are you unwaged? Are you earning under £10,000? Are you mainly parenting? None of the above apply. If you are not working, would you take a small job to help pay for your costs? Yes! No... If 'No', Please say why?:   Please do the Following: Please Enter Your Income Details Below. When you have entered your income details, press 'Calculate' If you are happy with the details, 'Click' to proceed to book an initial consultation   We will ask for proof of information that you are supplying. Do you have any sources of earned income? Do you receive Entitlement Benefits? Do you receive Means-Tested Benefits? Yes No Yes No Yes No Enter Weekly Amount Enter Weekly Amount Enter Weekly Amount Employment Over 16 Hours: £0 £300 £290 £280 £270 £260 £250 £240 £230 £220 £210 £200 £190 £180 £170 £160 £150 £140 £130 £120 £110 £100 £90 £80 £70 £60 £50 £40 £30 £20 £10 JobSeekers Allowance: £0 £200 £190 £180 £170 £160 £150 £140 £130 £120 £110 £100 £90 £80 £70 £60 £55 £50 £45 £40 £35 £30 £25 £20 £15 £10 £5 Income Support: £0 £200 £190 £180 £170 £160 £150 £140 £130 £120 £110 £100 £90 £80 £70 £60 £55 £50 £45 £40 £35 £30 £25 £20 £15 £10 £5 Employment Under 16 Hours: £0 £300 £290 £280 £270 £260 £250 £240 £230 £220 £210 £200 £190 £180 £170 £160 £150 £140 £130 £120 £110 £100 £90 £80 £70 £60 £50 £40 £30 £20 £10 Incapacity Benefit: £0 £200 £190 £180 £170 £160 £150 £140 £130 £120 £110 £100 £90 £80 £70 £60 £55 £50 £45 £40 £35 £30 £25 £20 £15 £10 £5 Housing Benefit: £0 £200 £190 £180 £170 £160 £150 £140 £130 £120 £110 £100 £90 £80 £70 £60 £55 £50 £45 £40 £35 £30 £25 £20 £15 £10 £5 Retirement Annuity/Pension: £0 £300 £290 £280 £270 £260 £250 £240 £230 £220 £210 £200 £190 £180 £170 £160 £150 £140 £130 £120 £110 £100 £90 £80 £70 £60 £50 £40 £30 £20 £10 Disabled Persons: £0 £200 £190 £180 £170 £160 £150 £140 £130 £120 £110 £100 £90 £80 £70 £60 £55 £50 £45 £40 £35 £30 £25 £20 £15 £10 £5 Council Tax Benefit: £0 £200 £190 £180 £170 £160 £150 £140 £130 £120 £110 £100 £90 £80 £70 £60 £55 £50 £45 £40 £35 £30 £25 £20 £15 £10 £5 Other Unearned income: £0 £300 £290 £280 £270 £260 £250 £240 £230 £220 £210 £200 £190 £180 £170 £160 £150 £140 £130 £120 £110 £100 £90 £80 £70 £60 £50 £40 £30 £20 £10 Maternity Benefit: £0 £200 £190 £180 £170 £160 £150 £140 £130 £120 £110 £100 £90 £80 £70 £60 £55 £50 £45 £40 £35 £30 £25 £20 £15 £10 £5 Working Family Tax Credit: £0 £200 £190 £180 £170 £160 £150 £140 £130 £120 £110 £100 £90 £80 £70 £60 £55 £50 £45 £40 £35 £30 £25 £20 £15 £10 £5 Maintenance Payments(self/Child): £0 £200 £190 £180 £170 £160 £150 £140 £130 £120 £110 £100 £90 £80 £70 £60 £55 £50 £45 £40 £35 £30 £25 £20 £15 £10 £5 Child Benefit: £0 £200 £190 £180 £170 £160 £150 £140 £130 £120 £110 £100 £90 £80 £70 £60 £55 £50 £45 £40 £35 £30 £25 £20 £15 £10 £5 Child Tax Credit: £0 £200 £190 £180 £170 £160 £150 £140 £130 £120 £110 £100 £90 £80 £70 £60 £55 £50 £45 £40 £35 £30 £25 £20 £15 £10 £5 State Retirement Pension: £0 £200 £190 £180 £170 £160 £150 £140 £130 £120 £110 £100 £90 £80 £70 £60 £55 £50 £45 £40 £35 £30 £25 £20 £15 £10 £5 Total of Earned Income: £0 Total Entitlement Benefits: £0 Total Means Tested Benefits: £0 If the details you have submitted are correct, then press the button. Calculate my fee This is the calculation of your income and our fees Weekly net income Total: £0.00 Annual Net Income: £0.00 Your contribution towards the fee is: £5.00 The Fee subsidy from LACAP is: £25.00 The Cost of the Treatment per session is: £30.00 The fee is assessed on your declared net income, grossed at taxed income rates. Please click on the link for more information. Fee Table If the fee is acceptable to you, go to the Appointment Maker Book an Appointment Now

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