Home support interest form

Please fill in this form if you are interested in arranging one-to-one home support in Wiltshire for yourself or for someone you care for. Please note we can only provide this service to clients who live in the Wiltshire area.

If you would like any help filling in the form or prefer to talk by phone, please contact us on 01380 739055.

As a charity we charge a subsidised rate of £27 per hour. You may be entitled to financial assistance from Wiltshire Council to help with this.

I'm referring for *
Your information
What is your relationship to the person you are referring
Does the person know that you are making this referral?
Who should be contacted about the referral?
Your information
DD/MM/YYYY
Which part of the county are you in?
Do you have a diagnosis of dementia?
Do you have a named dementia adviser?
Do you live alone?
How would you like us to contact you?
About the person being referred
DD/MM/YYYY
Which part of the county are they in?
Do they have a diagnosis of dementia?
Do they have a named dementia adviser?
Do they live alone?
Please tell us about anything else that you think is relevant to this referral.