Online Referral FOrm

Step 1

 Your details





Details about the person needing help





Address and Contact Details

Step 2

Help Needed
Please tell us more about the help you need. Include as much detail as you can. If you are filling in this form for someone else, please answer the questions as they apply to that person. 

What would you like to be able to do? What is currently preventing you? What have you already tried (if anything)?
Upload images


Do you have a formal diagnosis which you can share with us? How does your health impact on your ability to do things? How might your condition affect the way you use their equipment?

Who should be present during a home visit? Are there any days or times we should try to avoid? Are there any practicalities or risks which our volunteers should be aware of?

Step 3

We would love to keep in touch
We only contact people who have given us their specific permission to do so. We would like to keep in touch with you to keep you updated on our latest news, stories, fundraising and to ask for your feedback on our services.

Please tick the boxes to tell us what ways you would like to hear from us.

You can change your mind at any time by contacting us on 01732 760209 or data@remap.org.uk
Your details are safe with us. See link to Privacy Policy below this form.

Contact Information
Your Rights Under GDPR

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