Get Help From Remap

Please enter the postcode of the person requiring help, you will then be directed to our online referral form.

Please enter postcode

In completing this form you agree to providing information which will be used in accordance with Remap's "Privacy Policy.

Once submitted, please be patient as the system may take a few moments to process your application.

I would like help for

MyselfSomeone else

Your details

First Name

Last Name

Relationship to person being referred

Job Title

Organisation

Phone

Mobile

Street Name & Number

Town/City

County

Post Code

Disability categorisation

Sex

Age Range

Ethnic Group

Ethnic Background

Details about the person needing help

First Name

Last Name

Sex

Disability categorisation

Ethnic Group

Ethnic Background

Age Range

tick if same address and contact details as person making the referral

Address and Contact Details

Phone

Mobile

Street

Town/City

County

Post Code

Help Needed

Please tell us more about the help you need. Include as much detail as you can. If you are filling in this form for someone else, please answer the questions as they apply to that person.

What can we help you with?

What would you like to be able to do? What is currently preventing you? What have you already tried (if anything)?

Upload images

Please upload any pictures to help us understand the help needed (optional)

What is the nature of your illness or disability? How does it affect you day to day?

Do you have a formal diagnosis which you can share with us? How does your health impact on your ability to do things? How might your condition affect the way you use their equipment?

Is there anything we should know about if we need to visit you at home?

Who should be present during a home visit? Are there any days or times we should try to avoid? Are there any practicalities or risks which our volunteers should be aware of?

Any other comments?

Where did you hear about Remap?

Other

I have read and agree to Remap’s Privacy Policy and consent to my details being used in relation to my request and for Remap to contact me

tick to agree

Contact Information