Request for community support for individuals

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Government Letter

A letter has recently been sent to people who are extremely vulnerable to coronavirus. The title of the letter is ‘Important advice for you about new guidance for clinically extremely vulnerable people’.

Has the person who needs the support received this letter :

Yes
No

Who needs support?

Are you the person who needs the support? *

Yes
No

Permission to share details for community support

Your relationship to the person needing the support:

Do you have their permission to share their details with us? : *

Yes
No

Sorry you can’t request community support

Unless you have their permission to share their details with us unfortunately you can’t request community support.

Details of the person needing the support

Full Name: *

Surname: *

Date of birth:

Address

Enter the postcode with a space between 3rd and 4th character. Example TQ1 3DR

House name/number:

Postcode: *

Support needed

Describe the support needed: *

Contact details

Email address:

Telephone number:
If we call you our number will be withheld.

Do they live alone? *

Yes
No

Disabilities

Do they consider themselves to have a disability? *

Yes
No
Prefer not to say
Don't know

About the disability

How would you describe the disability?

Development disability

Learning disability

Mental health or emotional disability

Unseen disability

Physical disability

Sensory disability

Prefer not to say

Other

About the disability

Describe the disability: *

About the help or support needed

Please give more information about the help or support that is needed: *

Contact details

First name: *

Surname: *

Your address

Enter the postcode with a space between 3rd and 4th character. Example TQ1 3DR

House name/number:

Postcode: *

Contact details

Email address: *

Telephone number:
If we call you our number will be withheld.

Data protection

The information you have provided on this form will be used to deal your request by the relevant department. We may pass your details on to contracted third party service providers. We will store a copy of your completed request as a backup for 12 months.

If you would like to know more about how we use your information and how you can exercise your information rights please see our privacy notice.

Do you accept these terms and conditions