Adult Support Self-Referral

Please provide the below information about yourself.

 

If you have any questions ahead of making a referral, please contact the team at adult.support@daisychainproject.co.uk

Once submitted, a member of the team will be in touch as soon as possible. Please note that completing this form is not a guarantee of support.

 

Important Information:

  • We are not a crisis service.
  • We are not a 24-hour service.
  • We are not a complex mental health service.
  • We cannot provide in-home support.
  • Completing this form is not a guarantee of support.
  • We are a self-referral service, if you are a professional assisting someone to fill out this form, please ensure they are with you.
  • Previous criminal convictions are assessed on a case by case basis.
  • You must make us aware if your consent preferences or information changes.

 

Adult Support Service - Self Referral Form

Address(Required)
Current Benefits: (click all that apply)(Required)
Diagnosis Status(Required)
Have you been signposted to us from an ADHD or Autism waiting list?(Required)
If you need help finding your NHS number, please contact our team on adult.support@daisychainproject.co.uk.
Name, address, and telephone number.
What support would you like from us? (Tick all that apply)
GDPR(Required)
We need your consent to record and use your special category personal data. ·If you agree, we use this information to give you advice, help us gather data to improve our service, and support our research. ·Your data is used anonymously so that you cannot be identified.
Consent(Required)
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