Contact Disability Solutions West Midlands

Contact Us

To enable us to pass your enquiry to the correct department please carefully fill out this form.

I need help with: *

Which Benefit *

I need advice on: *

What Area are you in ? *

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 *

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.

Email

Contact Us

Referrer's Details

Please supply the details of the person requiring our help.

Disability Solutions West Midlands

OUR ORGANISATION

SERVICES

CHARITY POLICY