What do you need help with?

Are you elderly, disabled, or feeling vulnerable as a result of the unprecedented challenges and increasing isolation caused by COVID-19. 

Through the “Our Neighbourhood” initiative, we can all look out for each other and show a little kindness.

Please complete this form and we will contact you with the details of someone who can provide assistance:

My name is *

My address *

My email is

Contact Phone Number *

What do you need help with? Select all that apply

A friendly phone call (daily/weekly/occasionally)
A visit from a friendly face to chat
Picking up shopping that I have ordered from the local shops
Feeding animals as I usually have someone help me

Other tasks (please specify)

Can you please tell us a little information about your living situation? e.g. Live alone, no family locally

Do you currently receive any assistance from a community service organisation? i.e. Silverchain, Avivo, Disability support, home help. Please describe.

If you have any long term conditions such as diabetes, lung disease or heart disease and would like some follow-up support, do we have your consent to pass on your details to the WA Country Health Team?

YesNoNot Applicable

Please provide your next of kin details or primary carers contact details (Name, phone, email (if known))

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