Apply for Support

Tell us what support you are looking for

This form is for individuals and families. There are no wrong answers — share what you can and we will talk the rest through with you.

Your details

Full name *

Preferred name

Date of birth

Address

Phone

Email *

Preferred contact method

Support required

Type of support

Supported livingDomiciliary careCommunity supportCare supportOther

Tell us about yourself

Your routines, interests, culture, and what matters to you.

What do you need support with?

What would you like to achieve?

Preferred times

MorningAfternoonEveningOvernightFlexible

Current support

FamilyLocal authorityExisting providerNHSSelf-fundedOther

Emergency contact

Name

Relationship

Phone

Supporting documents

Optional — assessments, letters or anything else that helps us understand your needs.

Upload documents

PDF, Word or image files, up to 10MB each. Maximum 10 files.

Consent and data protection

I consent to ShieldsCare Limited storing and using the information in this form to respond to my enquiry, as described in the privacy policy.

What happens next

Call [INSERT PHONE] and we will complete it with you over the phone. A family member or advocate is welcome to apply on someone's behalf.

Domiciliary Care | Supported Living | Care Support

Supporting people to live with dignity, choice, confidence and independence.

Regulated services are provided subject to the relevant regulatory requirements and registration.