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The person needing services:

ADULT

ELDERLY

MALE

FEMALE

I am interested in services for:

MYSELF

RELATIVE

FRIEND

NEIGHBOUR

The sort of services needed may include: (Please tick all boxes which apply)

HELP WITH PERSONAL CARE

SUPPORTED LIVING

PREPARING & COOKING MEALS

CLEANING & LAUNDRY

SHOPPING OR OTHER ERRANDS

BEFRIENDING

Please advise us of the main problems experienced:

FRAILTY

CONFUSION

PHYSICAL DISABILITIES

LEARNING DISABILITY

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