Community support request form

The purpose of this form is to collect your contact details so we can help connect you to support from a volunteer in your community. We also ask some other questions to find out more about the kind of help you need.

The activities include (but not limited to) the following:

  • Welfare checks (wellbeing, heating working, food in fridge, no trip hazards in property, pendant alarm in place, no immediate risk of harm or neglect, no safeguarding concerns)
  • Making onward referrals as appropriate (key safe, carer support, befriending, meals on wheels, pendant alarms, cleaning, decluttering etc.)
  • Practical support with shopping, collecting prescriptions, food parcels, assistive equipment
  • Escalating any concerns over welfare
  • Checking in as agreed with service user over a period of time to ensure onward referral connection has been made and that they are okay

If you need any help completing this form, please contact Communities 1 st on 020 8207 5115 or email help@communities1st.org.uk

Details of the person requiring support
Form Filler Information
If you are filling out the form for someone else, please don't put your email in "Email (of the person requiring support)" or the support request will be assigned to your account and not the client's. If you don't have an email for them, please leave that box blank.
HCNS Details
Welfare check over the phone required?
Welfare check in person required?
Do they require practical support?
Additional Info
They
Are they a Carer?
What is their ethnic background?
Tell Us About Them
Do they have any underlying health conditions?
Do they live alone?
Do they have children under the age of 18 in the household?
Do they have any allergies?
Are they receiving support from social services?

By submitting this form, you are agreeing to your details being shared with local community groups, Council services and its health partners, so that we can help support as part of the Coronavirus response. The legal basis for this use is your consent. Your information will not be used for any other purpose. You can withdraw this consent at any time by contacting the email address given, and Communities 1st will remove your data and inform other providers to do so. Our full privacy statement giving your rights is online, or ask us for an accessible copy.