Request help for myself

URL
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About you
Where do you live?*
We are able to support people who live either in Bedford Borough or Central Bedfordshire.
- Bedford Borough
- Central Bedfordshire
Your date of birth*
Day
Month
Year
Your first name*
Your last name*
Your address*
Postcode*
Contact telephone number*
Email address (optional)
Your email address if you would like to be contacted via email.
The name of your GP's surgery*
Ethnicity*
Employment status*
- Employed full time
- Employed part time
- Retired
- Unemployed
- Other

What help do you need?
How can we help?*
We offer free support to help people make positive changes to improve their health and wellbeing. Can you say more about the help you need?
Disability
Are you disabled?*
Do you (or the person you are enquiring for) have a physical or learning disability that we need to be aware of?
- No
- Yes
Further disability information
If yes please say more.

Data protection
The Community Referral Service is run by Bedfordshire Rural Communities Charity (BRCC)

By completing this form you agree to engage with the Community Referral Service and that we can use your information on your behalf to share with other relevant organisations for the purpose of providing this service. It will be kept on a secure computer system in accordance with the General Data Protection Regulation.

To find out more please read our privacy policy.
Your consent*
- I give my consent for BRCC to record my personal information so that I might engage with the Community Referral Service
- I authorise BRCC to pass my contact details onto the relevant organisations and groups that might be able to offer me help and support
- I have been made aware of BRCC’s privacy policy and know where I can download a copy
Spam protection

About you