Contact Us To enable us to pass your enquiry to the correct department please carefully fill out this form. I need help with: * Please Select Form Filling Benefit Appeals Advice and General Guidance Which Benefit * Please Select Personal Independence Payment Pension Credit Universal Credit Attendance Allowance Disability Living Allowance Carers Allowance Employment Support Allowance Not Sure, Advice needed. I need advice on: * Please Select Benefits Personal Wellbeing What Area are you in ? * Please Select Stoke on Trent Staffordshire West Midlands Newcastle U Lyme Are you filling this form out for yourself or a family member/client? * Self Family member/Client Referrer's Details Referrer's Name: * Referrer's Organisation * Referrer's Email Address * Referrer's Contact Details * Date of Referral * Care Coordinators Name: * Please supply the details of the person requiring our help. Title * Mr Mrs Miss Ms Dr. Prof. Mx First Name * Surname * Address * Postcode * Phone Number * Email Address D.O.B * National Insurance Number Gender * Male Female Other Nature of Disability * Ethnic Group * Prefered language * Housing Status * Employment Status * Brief details for referral: * Current Benefit/s claimed. * Health Safety and/or safeguarding Issues: * Does the person named above or their representative give verbal consent for a referral to be made to Disability Solutions Benefits Service? * Yes Please Confirm You Have Read The Contribution Policy (Not applicable to SOTWBT and MAC team referrals. * Yes Contribution Policy Please make sure you have correctly stated the required benefit, failure to do so will result in a delayed response from us as your email will be incorrectly routed. reCAPTCHA * SEND Message
To enable us to pass your enquiry to the correct department please carefully fill out this form.
Contribution Policy
Please make sure you have correctly stated the required benefit, failure to do so will result in a delayed response from us as your email will be incorrectly routed.
