Telecare services request form

You can use this form to apply for Telecare services, for yourself or someone you look after.

Before you apply, if you have not already done so, you may find it useful to use the Telecare self-check tool, which asks you some questions about you and your needs, then provides Telecare specific and general advice based on your answers (there is no need to enter any personal data)

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You can use this form to request Telecare services, which include alarms and sensors for your home.

There is a charge of £5.75 a week for Telecare services.

Once you have submitted your request, a member of the team will get in touch with you to arrange the right services for your needs.

Are you applying for yourself or on behalf of someone else?

For myself

On behalf of someone else

If you are applying on behalf of someone else, would you like the correspondence to be sent to a different address? If yes, please tell us the correspondence details below

Yes

Correspondence / contact details (if different from customer details)

Contact name

Contact address (including postcode)

Home telephone number

Work telephone number

Mobile telephone number

Relationship to keyholder

Personal details

Title (e.g. Mr, Mrs. Miss, Dr) *

First name *

What name do you prefer to be called by?

Surname *

Date of birth

Day

Month

Year

Address

Postcode

Contact phone number *

Please give us the phone number you would like us to use to contact you

Does anyone else live in the house with you?

Yes

Sometimes

Please tell us the name(s) of who else lives in the house with you, and their relationship to you

Who is your phone provider?

Some telephone suppliers may not guarantee to support Telecare sytems. If your supplier is not BT, please check with your supplier that they do support Telecare systems

Leave this field blank

Argyll and Bute Council

Telecare services request form

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