Request for Support

If you are vulnerable or in need of some support during this difficult time we have volunteers that are happy to help and still comply with government guidelines.

What do I do first?
Please complete the form below so we can understand what you need support with

What happens next?
One of our team will contact you during the next working day.

Please be aware that we can only accept applications from people living in Essex

First Name Required

Surname Required

Date of Birth Required

NHS Number

Address Details

House Name or Number Required

Street Required

Town Required

Postcode Required

Your Contact Details Please provide at least one method of contact or ideally as many as you can, to make it easy for us to reach you.

Email Address

Phone Number

Mobile Phone

Secondary Contact (Friend / Family / Next of Kin)

Secondary Contact Name

Secondary Contact Phone Number

Preferred method of contact Required

Medical Information

Do any of the below apply to you? Required

Diabetes

Heart Disease

Kidney Disease

Liver Disease

Low Immune System

Mental Health

Pregnancy

Respiratory Issues such as COPD

Carer

Prefer not to say

Other (if applicable)

Reason for Referral

How can we help you at this time? (Please select all that apply) Required

Being a FB Friend

Being a Phone Friend

Collecting / Delivering Medicines

Dog Walking

Exercise

Food Shopping

Gardening

Healthy Lifestyle Advice

IT Support

Outside Maintenance

Posting Mail

Supporting a Carer

Transportation

Do you currently have any support in place to help you during the COVID-19 situation? (Please select all that apply) Required

None

Friends / Neighbours

Family

Local Support Group

If selected, please provide the name / description of the Local Support Group

Are you presently receiving support from any of the below?

Adult Social Care

IAPT / EPUT

Other (if applicable)?

The information you provide to us will be used for the purposes of the Covid-19 related programme of activity. By submitting this form, the information will be sent to the Essex Welfare Services team who will contact the referred individual in order to discuss their needs. Certain information may also be shared with a volunteer working in conjunction with the organisation in order for them to provide the requested support to them. We may pass their details onto organisations and individuals who are supporting the community with this programme as well as Essex County Council who commission this service. The information submitted will only be shared where required and to those with a need to know. How we use and share this information is further explained in our privacy policy .

By submitting this form, you confirm that you have informed and/ or sought the permission of the person who you are referring.

Do you know someone in need of support?

If you would like to refer someone to receive support during this period, we're here to help.

Make a referral now

Are you looking to volunteer?

We have lots of volunteering opportunities available to support people who are vulnerable or in need during this period.