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To get you the support you need we may need to share your personal information with other health and social care services.Without the ability to share your personal information with other health and social care services, we may not be able to help you properly.
You need to tell us your full name.
You need to tell us your address .
You need to tell us your postcode.
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You need to tell us your phone number.
You need to tell us what describes where you live.
You need to tell us why you are contacting us today.
Are you able to You need to tell us which activities you are able to perform.
You need to tell us how your health is affecting how you currently live.
You need to tell us what you think could help you with current situation.

We are committed to making equal opportunities a reality in the provision of all of our services. We need to know who our
customers are to check that everyone in the city is accessing the services they are entitled to and that no-one is discriminated against
unlawfully. Information provided will be treated confidentially and in accordance with the Data Protection Act 1998 and only used to ensure that
everyone is treated fairly.

How would you describe your ethnic origin?
White
Mixed / multiple ethnic groups
Asian / Asian British
Black / African / Caribbean / Black British
Other Ethnic Group
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