COVID-19 Register for help

Please complete this form if you could benefit from support or know someone that would.

Please ensure you have gained consent from the person you are filling in the form for.

Consent

Please provide at least one means of contact

Gender
Do you classify yourself as BAME?
Have you been contacted by Track and Trace?
Has the client had a government food parcel?
Has the client registered online to the Government's Coronavirus Extremely Vulnerable List
Is this person...
Support Required