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Worcestershire County Council
Request For Help
Instructions
Please fill in this form if you require assistance or support in Worcestershire.
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1
Your Details
First Name
Surname
Preferred Contact Method
Telephone Number
Email
Email
Phone Number
For security reasons, please choose a code word that we can repeat to you when you are contacted about the information you have provided in this form
Please use the postcode finder below to locate your address. If your address does not appear in the list, please select the 'My Address is not in the List' option, and fields will appear for you to enter your address manually.
Please enter your postcode, find the address, then select from the list
Postcode
Please enter a valid Worcestershire postcode, e.g. WR1 1PT
Don't know your postcode?
Find it here
-- Please Select Your Address --
Does anyone under 18 live in the household?
-- Please Select --
Yes
No
Are you self-isolating following a positive COVID 19 test result or as a close contact?
-- Please Select --
No - I am not self-isolating
Yes - I have tested positive for COVID-19
Yes - I am a close contact of someone with a positive COVID-19 test result
Yes - Other Reason
Are you clinically extremely vulnerable or clinically vulnerable?
Yes
No
Do you require an interpreter?
-- Please Select --
Yes
No
2
Details Of Help Required
Please select the categories in which you need help (please tick all that apply)
Food and Supplies
e.g. collecting and delivering food and supplies, emergency food support
Health and Medication
e.g. help with collecting prescriptions
Commitments
e.g. pet needs
Connectivity and Entertainment
e.g. access to the internet
Mental Health and Wellbeing
e.g. befriending and support for those feeling isolated
Business and Money Matters
e.g. advice around money, benefits and debt
Support for Ukrainian Guests
Practical support (not providing housing) for Homes for Ukraine / Ukraine Families Visa scheme guests, hosts, families and supporters
Support to register on National Shielding Service System
Only select if you are clinically extremely vulnerable (CEV) and need support to register on the NSSS
Other
Please tell us as much information as you can about the help you need
Please note that we may need to share details with third parties in order to mobilise help for you. Please confirm if you agree to us sharing your information with:
Third party organisations e.g. your local council, voluntary, community and charities who may be able to offer you help or support.
An individual who has offered the type of help or support you require.
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