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Care Seekers Enquiry
Please tell us a bit more about the support you are seeking by completing the form below. If you prefer, please call and we will be happy to help 01494 578127
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* Indicates required question
Email
*
Your email
I am seeking care for
Myself
Someone else
Clear selection
Your first name
Your answer
Your Family name
Your answer
Your phone number
*
Your answer
How would you prefer us to contact you
email
phone
sms
no preference
Clear selection
What type of support are you looking for
Hourly care (someone to call in during the day, one or more times)
Live in (living in your home full time)
Overnight ( either sleeping or awake, one or more times a week)
Not sure yet (please call us to discuss further 01494 578127)
Other:
What type of activities are you needing support with
personal care and hygiene
General home help
Trips out
Companionship
Shopping
Food preparation
Giving medication
Other:
Location where care is required full address including post code
Your answer
Is care needed
Choose
Short term (up to 6 weeks)
Long term (more than 6 weeks)
Estimate of Number of hours per week
Your answer
Ideal Start date
MM
/
DD
/
YYYY
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