Equipment, Adaptation and Sensory Loss Referral Form

Before you start

You can use this form to enquire about some equipment or home adaptations for yourself or someone else.

To be eligible for help you need;

  • to be 18 years old or over
  • to have a disability, illness or injury, or sight or hearing loss

Once we have received your enquiry we will contact you to arrange an assessment. Assessments can be arranged quicker if your situation is urgent. Often, people returning home after hospital and those who may be at risk are given the highest priority.

For further information about eligibility, types of equipment available and adaptations, visit the My Care My Choice website

Start now

How we use your data

We primarily use your data for processing your enquiry. This may be shared with other government departments in accordance with our organisational privacy notice. We never sell your data to third parties or use it to market to you without your consent.