Submit a Request for Support

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Self Referral

This assessment is intended for any adults (18 years of age or over) who either have themselves or care for someone with a serious illness, physical disability, learning disability, mental health problems or frailty as a result of aging. Completing this assessment will help us to identify the support we can provide for you or the person you care for.

If you need advice on finding care and support options available to you then please complete Request for Care & Support form instead.

This assessment is intended for any adults (18 years of age or over) who either have themselves or care for someone with a serious illness, physical disability, learning disability, mental health problems or frailty as a result of aging. Completing this assessment will help us to identify the support we can provide for you or the person you care for.

If you need advice on finding care and support options available to you then please complete Request for Care & Support form instead.

 This form will take 10-20 minutes to complete. image. This form will take 10-20 minutes to complete.
What will I need to complete this form?
You will be required to create an account, or log into an existing account, in order to complete and submit this form.

Please provide as many details as possible about the situation you feel we could support you with. Doing this enables us to give your request the correct priority. Without this information we may not be able to correctly identify any support you may need and so you will need to contact us again.
How long will it take?
This form will take 10-20 minutes to complete depending on the amount of information you need to provide.

Please be aware that for security reasons your session will timeout after 20 minutes of inactivity.
Saving your assessment
Please save your form regularly using the 'Save for Later' button at the bottom of the screen. This form will then be available for 31 days in your list of My Saved Forms.

Once you have submitted the form you will be able to see a copy in the ‘My Submitted Forms' section of the portal for 365 days; after this the form will no longer be visible.

To print the form use the 'Print' button at the bottom of the screen before submitting.
What other useful contact numbers are available to me?

  • You can also share a concern about an adult or report alleged abuse directly to the Safeguarding Adults Team (MASH) on 0800 137915
What further information is available to me?
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