By submitting this form you are providing consent for notes to be added to your account(s) so we are aware of any action we need to take in relation to giving extra support. This consent can be withdrawn at any time.

Please note:

  • only customers and authorised representatives are able to provide consent.
  • we may need to share your personal information with third parties but will only do so with your consent at point of disclosure or where necessary to ensure Safeguarding.

Please answer the questions below

Your details

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Support details



As circumstances can change over time, we offer reviews periodically to ensure support remains appropriate and so we only hold information for as long as necessary.

Please tell us your review preference:

Review – We will contact you to discuss your support needs around your preferred date.

No Review

– Please select this option if you don’t think your needs will change and would prefer not to have a review. We will still write to you periodically to remind you some extra help is in place.

If we need any further information or to clarify any details to ensure we can offer the right support, then a member of our specialist team will be in touch on the contact details provided.

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Please note: we need all the information marked with an * asterisk.
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