Care Network (Blackburn with Darwen) Ltd | Help Link Self Referral Form

Full name *

House number and street name *

Postcode *

Date of birth *

Telephone number

Email address

NHS number (if known)

How would you like us to contact you? *

By phone (please leave a voicemail if I don’t answer)By phone (please don’t leave a voicemail / I have no voicemail)By emailBy post - please send me the information through the postI don’t mind - please contact me any way

Consent to contact you *

Please tick to confirm we can contact you

Is your enquiry regarding yourself or someone else

Consent to share information *

You give consent for your personal details to be used for a referral in to appropriate support servicesI understand that the purpose of providing this information is to maximise the benefits to my general health and wellbeing and that I can refuse any services I wish toI understand that I can stop the information sharing at any point by contacting Care Network and that only the minimum amount of information necessary will be shared

Would you like to receive more information from Care Network and the Help Link Hub that may be of interest to you?

No, thanks Yes, please

Brief overview of situation

I have recently had a fall / I am afraid of falling I need help with health condition / sensory impairmentI would like a Healthy Homes assessment to identify and reduce the environmental hazards that increase the risk of fallingI would like access to Care Networks Safe Trader Scheme as my home needs repairs / DIY I am struggling to keep my house warm / pay my fuel bills I need help to manage a low income / I have debt issues I would like a fire safety check / smoke alarm I want or need to move homeI support or care for someone with an illness or disability I feel lonely or isolated I would like to know how to live a healthier lifestyle e.g stop smoking, exercise, weight management I need support to live independently e.g. shopping, footcare, meals, gardening (please give details below)I have recently been bereaved I need information or support to access health and social care services I would like to work and discuss employment options, volunteer or access training and learning I need information about transport

Please use this space to tell us a little more about your issue