Support enquiries - United Response

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About you

Who are you requesting support for?(Required)

Yourself

Someone else

What's your relationship to the person needing support?(Required)

Parent

Sibling

Other family member

Friend

Social worker

Other professional

What organisation do you represent?(Required)

Name of the person requiring support

First Last

Your name(Required)

First Last

Your email(Required)

Enter Email Confirm Email

Your phone number(Required)

Address

Street Address Address Line 2 City County Post code

Funding

Do you have funding in place?(Required)

Yes – a local authority personal budget, direct payments or a care managed budget

Yes – support will be funded privately

Please share a summary of the funding package

Funding

Funding (local authority or personal budget) must be in place to access support.

Find out about local authority funding and whether you are eligible
If you are not eligible for local authority funding, you will need to pay for your care. Find out about self-funding your care

About the new support that’s required

What diagnoses or condition does the referral need to meet?

Learning disabilities

Physical disabilities

Autism

Mental Health needs

What type of support is needed?(Required)

Everyday living support in your own home

Somewhere to live with someone to support you

To find a job

Education and skills

Accessing activities for wellbeing

What is the gender of the person seeking support?

Male

Female

Non-binary

Other

What is the age of the person seeking support?

Please enter a number greater than or equal to 0.

What other support do they already receive?

Please advise if this support has ended, or may end soon.

Which town or area will the support be needed?(Required)

In the next question, where relevant it would be helpful to know details about forensic histories, challenging behaviour, substance misuse or sensory needs.

Please tell us anything else about the support needed

For example, please tell us more details about the person needing support, and if relevant the days and times that support is needed.

How we will use your information

Filling in this form helps us connect you with the right local team, who can provide the kind of support you need. Please include as much detail as you can. We endeavour to respond within five working days.

By completing and sending this form, you are consenting to be contacted by United Response staff using the details you give us.

We will never share the information you submit with any third party. But we may use your information internally to make sure we’re providing a good service.