Please note this service is for Wolverhampton residents only.

Any information submitted as part of a referral or self-referral application will be shared with Wolves Foundation and/or ACCI, who will use it to consider the support request, to contact the relevant individual to obtain more information (if necessary) and, if the support request is successful, to facilitate delivery of the item(s). They will each process the personal data shared with them in accordance with their own privacy policies (Wolves Foundation Privacy Policy and ACCI Privacy Policy). By submitting an application form, you confirm that you consent to the data entered being used and shared in this way – if you do not consent to this, you should not submit the information.


If you are submitting an application on behalf of another person (i.e. by completing a referral application) then, by submitting the form, you also confirm that you have the consent of that person to do so and for that data to be shared with Wolves Foundation and/or ACCI as described above. If this is not the case, you should not submit the application form.

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Referral Organisation


Customer details

Customer name
Title

Address

Customer address


Contact

Contact details

Family details

Person 1

Person 1 gender
Does this person have disabilities as this will impact on the type of bed and mattress they will need?
This will also include mental health, learning disabilities, physical disabilities, age related disabilities etc
Person 1 employment status
Does person 1 receive any benefits?
Has person 1 previously received Household Support?
Is person 1 receiving support from any other organisation?

Add another person

Person 2

Person 2 gender
Does this person have disabilities as this will impact on the type of bed and mattress they will need?
This will also include mental health, learning disabilities, physical disabilities, age related disabilities etc

Add another person

Person 3

Person 3 gender
Does this person have disabilities as this will impact on the type of bed and mattress they will need?
This will also include mental health, learning disabilities, physical disabilities, age related disabilities etc

Add another person

Person 4

Person 4 gender
Does this person have disabilities as this will impact on the type of bed and mattress they will need?
This will also include mental health, learning disabilities, physical disabilities, age related disabilities etc

Add another person

Person 5

Person 5 gender
Does this person have disabilities as this will impact on the type of bed and mattress they will need?
This will also include mental health, learning disabilities, physical disabilities, age related disabilities etc

Add another person

Person 6

Person 6 gender
Does this person have disabilities as this will impact on the type of bed and mattress they will need?
This will also include mental health, learning disabilities, physical disabilities, age related disabilities etc

Items needed



Other details

Other family details

e.g. other health issues, cultural issues, pets etc.

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