Request for Support

If you are in need of some support we have volunteers that are happy to help and still comply with government guidelines.

What do I do first?
Please complete the form below so we can understand what you need support with

What happens next?
One of our team will contact you within 3 working days.

Please be aware that we can only accept applications from people living in Essex

Required
Required
Required
Address Details
Required
Required
Required
Required
Your Contact Details Please provide at least one method of contact or ideally as many as you can, to make it easy for us to reach you.
Secondary Contact (Friend / Family / Next of Kin)
Medical Information
Required
Reason for Referral
Required
Required

The information you provide to us will be used for the purposes of the Covid-19 related programme of activity. By submitting this form, the information will be sent to the Essex Wellbeing Services team who will contact the referred individual in order to discuss their needs. Certain information may also be shared with a volunteer working in conjunction with the organisation in order for them to provide the requested support to them. We may pass their details onto organisations and individuals who are supporting the community with this programme as well as Essex County Council who commission this service. The information submitted will only be shared where required and to those with a need to know. How we use and share this information is further explained in our privacy policy.

By submitting this form, you confirm that you have informed and/ or sought the permission of the person who you are referring.

Do you know someone in need of support?

If you would like to refer someone to receive support, we're here to help.

Make a referral now