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 *

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.

SEND

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Disability Solutions West Midlands

North Staffordshire Medical Institute
Hartshill Road
Hartshill
Stoke on Trent
ST4 7NY
Telephone: 01782 638300 

or email us