Referral form to request a call back

The Care Advice Line can help you make informed choices about your long term care and specifically how you pay for it.

We can provide tailored information and advice about care and support to suit individual personal circumstances.

This is a free and independent service which is available to people who live in Gloucestershire.

If you would like us to contact you please fill in your details below. We will contact you within five working days (this could be longer during busy periods or bank holidays).

If you are enquiring on behalf of someone else you will need to have that person's permission before we can talk to you about specific personal circumstances. Without this permission we can only provide general information and advice.

Customer name*

Representative (if applicable)

Telephone number*

Alternative number

Email address*

Local Authority*

Please note that this service is only available to people that live in Gloucestershire.

Organisation (if applicable)

Who should we call?*

Please confirm that you have been given permission to share these details by the customer or their representative. A request cannot be accepted without this.

Confirm*

YesNo

Please advise of any particular requirements we should be aware of before calling the customer or representative. For example, communication needs or if the person is hard of hearing and needs time to prepare for the call.

Comments / Brief Details

Telephone calls may be recorded for training and monitoring purposes.