Self-isolation welfare support

Your details
Name

First name

Last name
Date of birth
Your address
House number
Street name
Town
Postcode
Your contact details
Phone
Does the telephone accept calls from unknown numbers?
Email
Details of others in the household
Please provide details of anyone else in your household
Name

First name

Last name
Date of birth (or confirm exact age if not known)
Does their telephone accept calls from unknown numbers?
Phone
Email
Please provide details of anyone else in the household, including name, date of birth, phone number and email address
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Details of the person who needs support
Name

First name

Last name
Date of birth
Age or approximate age (If the date of birth is not known)
Address of person who needs support
House number
Street name
Town
Postcode
Contact details of person who needs support
Phone
Does their telephone accept calls from unknown numbers?
Email
Details of others in the household
Please provide details of anyone else in the household of the person who needs support. If there is no one else in the household, please leave this section blank.
Name

First name

Last name
Date of birth (or confirm exact age if not known)
Phone
Does their telephone accept calls from unknown numbers?
Email
Please provide details of anyone else in the household, including name, date of birth, phone number and email address

Your details
Please provide your details below if you are a resident contacting us on behalf of a family member, friend or neighbour.
Name

First name

Last name
Email
Phone
What is your relationship to the person who needs support?
If you selected other, please choose from the list below
If your relationship to the person who needs support isn't listed, please provide it below

Further information about the person who needs support
Do they have access to the internet, eg. online shopping?
Do they need digital support?
If yes, please describe the issue they need help with?
Connecting with friends and familySetting up an email addressShopping onlineBanking onlineOther
If other, please state the issue below
If they need digital support, please choose what device they are using from the list below
If other, please state the device below
Has the person who needs support received information to advise that they are on the shielded list and must self-isolate for 12 weeks?
Are you/they self isolating due to any of the following:
Age or health conditionsA member of the household displaying symptomsThe person who needs support is displaying symptoms
Do you/they have family, friends or neighbours who can help with shopping, prescriptions or any other basic needs?

Further information about you
Do you have access to the internet, eg. online shopping?
Do you need digital support?
If yes, please describe the issue you need help with?
Connecting with friends and familySetting up an email addressShopping onlineBanking onlineOther
If other, please state the issue below
If you need digital support, please choose what device you are using from the list below
If other, please state the device below
Have you received information to advise that you are on the shielded list and must self-isolate for 12 weeks?
Are you self isolating due to any of the following:
Age or health conditionsA member of the household displaying symptomsYou are displaying symptoms
Do you have family, friends or neighbours who can help with shopping, prescriptions or any other basic needs?

What are the details of your enquiry and what kind of support do you require?
Please tick to confirm that you are happy for your contact details to be shared with volunteers / community groups / organisations who are working with us to provide you the support you need.
I confirm the above

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