Apply for a TeleCareLine

About you
1. Is someone helping you to complete this form?*
  
  Yes
  
  No
2. 1. Let us know about the person helping you
  2. Name of person helping
  3. Their relationship to you
  4. Their email address
  5. Their telephone number
3. 1. Do you have communication difficulties?
    
    Yes
    
    No
  2. Do you have any difficulties with understanding and/or retaining information?
    
    Yes
    
    No
  3. Do you have any difficulties making decisions and/or understanding their impact?
    
    Yes
    
    No
  4. Your answers indicate that you are completing this form by yourself and that you have difficulties with communicating, understanding information and/or making decisions.
    
    As a result, we think that you might benefit from support to help you complete the screening tool.
    
    Call us on 01895 556633 to discuss your needs.