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Home Gadgets Self-referral Form
Self-referral Form
If you are completing this form on behalf of someone else, you must ensure that you have obtained their consent to make this referral. If you do not have consent, you can complete an Enquiry form on our website.
*
1.
Name of person needing equipment
(Required.)
Title
First Name
Surname
2.
Details of the person who should be contacted to discuss this referral.
Title
First Name
Surname
Relationship to person needing equipment
Telephone Number
Email Address
For the following questions, please answer with the information of the person needing the equipment
*
3.
Address of the person needing the equipment
(Required.)
House Name/Number
Street
City/Town
Postal Code
County
*
4.
Date of birth of the person needing the equipment
(Required.)
*
5.
Ethnicity of the person needing the equipment
(Required.)
Asian Bangladeshi
Asian British Bangladeshi
Asian British Indian
Asian British Other
Asian British Pakistani
Asian Indian
Asian Other
Asian Pakistani
Black African
Black British African
Black British Caribbean
Black Caribbean
Chinese
Irish Traveller
Mixed Other
Mixed White Asian
Mixed White & Black African
Mixed White & Black Caribbean
Romany Gypsy
Scottish Traveller
Other Traveller
White British
White European
White Irish
White Other
Not Stated
Other
*
6.
Please tick tenure type:
(Required.)
Home owner
Council/Housing Association tenant
Private tenant
Living with family
