To get in touch with Adult Social Care or to request a care assessment, please fill out the form below. Current Start Preview Complete Please select the type of support you are enquiring about Personal care (e.g. washing, dressing) Support with meals/mealtime Support with medication Mobility assistance Wellbeing, companionship and social interaction Equipment, aids and adaptations Finances and managing your money Paying for care Advocacy Accessing the community Housing Other… Enter other… Are you contacting us for yourself or someone else? Yourself Someone else Your details Name Your name Title Title - Select -MissMsMrMrsDrOther…- Select -▾- Select -MissMsMrMrsDrOther… Enter other… First name Last name Address Your address First line of address Second line of address City/Town Postcode Contact Contact details Email Phone Other details GP details Date of Birth Relationship details Are you a carer? Yes - Professional Yes - Family Member/Friend/Neighbour No Has the person you are enquiring about given their consent to contact us on their behalf? Yes No Unable Please provide reason What is your relationship to the person needing support? Details of the person you are contacting us about: Name Name of the person you are applying for Title Title - Select -MissMsMrMrsDrOther…- Select -▾- Select -MissMsMrMrsDrOther… Enter other… First name Last name Address Address of the person you are applying for First line of address Second line of address City/Town Postcode Contact Contact details Email Phone Other details Date of Birth GP details of the person you are contacting us about Enquiry details What are your main difficulties? What are the person’s main difficulties? How do you think we can help? What support do you currently receive? This can be from friends/family/professionals. What support do they currently receive? This can be from friends/family/professionals. Do you have any disabilities and/or health needs? Yes No Does the person you are contacting us about have any disabilities and/or health needs? Yes No Provide details of disabilities and/or health needs Are there any health conditions or medical concerns? Please provide details: Do you have any difficulty communicating? Yes No Do they have any difficulty communicating? Yes No Provide details of communication difficulties Declaration By submitting this form, I confirm that the information provided is accurate to the best of my knowledge. I confirm 15686
