Self-isolation welfare support

First name

Last name

Date of birth (dd/mm/yyyy)

Phone

Does the telephone number accept calls from unknown numbers? Please select --> Yes No Don't know

Email

How many other people live in the household? None One Two Three Four Five Six

Do you have access to the internet e.g. online shopping? Please select --> Yes No

Have you received information to advise that you are on the shielded list and must self-isolate for 12 weeks? Please select --> Yes No

Have you registered yourself on the GOV.UK website to let them know whether or not you need support? Please select --> Yes No

While we can provide support in the meantime, you must register on the gov.uk website to ensure central government are aware of your needs.

If you are on the shielded list and have already registered to start receiving support, do you require assistance from us to help bring the food parcel into the house? Please select --> Yes No

Are you self-isolating due to any of the following? (select as many as necessary) Age or health conditions A member of the household displaying symptoms You are displaying symptoms

Do you have family, friends or neighbours who can help with shopping, prescriptions or any other basic needs? Please select --> Yes No

How much support is needed? Please select --> One-off support Ongoing support

What kind of support do you require? (select as many as necessary)

Food / household items delivery

Prescription collection

Someone to talk to

Financial support / advice

Digital support

Please provide any further information that we may need to be aware of 0 of 500 characters

All information submitted via this request will be managed in accordance with our Emergency Planning and Service Delivery Privacy Notice

I am happy for my contact details and information provided above to be shared with volunteers / community groups / organisations who are working with us to provide the support needed Please select --> Yes No

I am happy for my details to be checked against the National Shielded list to ensure I am receiving the correct support Please select --> Yes No