Welcome to Health and Social Care

Fields marked with (required) must be filled in.

Surname (required)

First Name (required)

Date of Birth (required)
1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th 15th 16th 17th 18th 19th 20th 21st 22nd 23rd 24th 25th 26th 27th 28th 29th 30th 31st   January February March April May June July August September October November December   

Address (required)
Insert address

Postcode (required)

Telephone Number (required)

Email Address (required)

If you have had a service from the Department previously.
What was it and approximately when did you last receive a service?
Insert comment

This section is optional but in order to provide a fair and equal service it will help us if you complete it ( please click the appropriate boxes )

What is your ethnic group?
I would rather not say

White British
English
Scottish
Welsh
Irish
Any other white background

Mixed
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background

Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background

Black or Black British
Black Caribbean
Black African
Any other Black background

Chinese or other Ethnic Group
Chinese
Any other Ethnic background

To identify how best to assess your needs please complete the following section.

Disability (If more than one choice, hold the control key down as you make your selection) (required)
No Physical Disability Mental Health Needs Learning Disability Hearing Impairment Visual Impairment Other

If you have selected 'Other', Please briefly explain (required if 'Other' selected above)
Insert explanation

Reason for Contact (If more than one choice, hold the control key down as you make your selection) (required)
Respite / A break from caring for an adult Child Care including a break from caring Difficulties in managing at home Family difficulties Help with drugs or alcohol abuse Other

In order that the request can be directed to the correct person please select from the list below.

Is the person needing care (required)
under 18 years of age 65 years or older under 65 years with a learning disability under 65 years with a mental health problem (includes drugs) under 65 years with a physical disability (includes alcohol)