Equipment, adaptation and sensory loss referral form
Before you start
You can use this form to enquire about equipment or home adaptations for yourself or someone else.
To be eligible for help you need to:
- be 18 years old or over
- have a disability, illness or injury, sight or hearing loss
Once we've received your enquiry we'll contact you to arrange an assessment.
If your situation is urgent an assessment can be made more. If you're returning home from hospital, or at risk, you'll be given the highest priority.
For more information about eligibility and the types of equipment and adaptations available, visit our equipment and adaptations pages page.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.