How Can We Help? 1A Bit About You...2About the Service You Need...3Availability Your Details First Name* Last Name* Email* Phone Number* AddressAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Who Are You Enquiring For? *Who Are You Enquiring For?*MyselfMy Partner/SpouseMy Parent(s)FatherMotherA RelativeA FriendA NeighbourOtherFirst Name Last Name What Do You Need Help With?What do you need help with? Preparing a Meal Cleaning Walking Getting In/Out of Bed Showering or Bathing Socialising Provide family carer with a break Companionship in the day 24 Hour Assistance Care/Assistance in the night Medication Prompts Medical Administration Diagnosed ConditionsDiagnosed <span>Conditions</span>Age Related CataractsAge Related Macular Degeneration (AMDAlcohol MisuseAlzheimer's DiseaseArthritisAsperger SyndromeAutism Spectrum DisorderBipolar disorderBlindBroken BonesBulimiaCancerCardiovascular Disease (CVD)Carpal Tunnel SyndromeCerebral PalsyCOPDCoronary Heart Disease (CHD)Crohn's DiseaseCystic FibrosisDeafDementiaDepressionDiabetesDiabetes Type 1Diabetes Type 2Down's SyndromeDyslexiaDysphagiaDystoniaEczemaGoutHepatitisHerniaHigh Blood PressureHigh CholesterolIncontinenceMyalgic Encephalomyelitis (ME)Hip ReplacementHivesHIV and AIDSHuntington's DiseaseKidney DiseaseKidney InfectionKnee ReplacementLearning DisabilityLyme DiseaseLymphocytic LeukaemiaMalnutritionMotor Neurone Disease (MND)Multiple Sclerosis (MS)Muscular DystrophyOCDObesityOsteoporosisPacemaker ImplantationParkinson's DiseasePhysical DisabilityRheumatoid ArthritisStrokeUrinary Tract Infections (UTIs)Visual ImpairmentNonePlease Specify Preferred Gender Of Care CompanionPlease SelectMaleFemaleEitherWhat visits do you require (if known)?What is your weekly budget (if known)? Days You Are Available For An AssessmentPlease select the days and times you are available Monday Tuesday Wednesday Thursday Friday Times You Are AvailableSelect times availablePlease SelectEarly MorningMid MorningMiddayAfternoonEveningPotential Care Start Day DD slash MM slash YYYY HiddenLead StatusActiveJoinedJoined (Now Closed)ClosedHiddenWhere did you hear about usWebsiteWord of MouthMarket StallSearch EngineFlyerNewspaperMagazineSocial MediaCCGLocal AuthorityDirectoryOwn LeadRefused To SayFacebook AdHiddenEnquiry MethodWebsite FormPhoneEmailFace-to-FaceWebsite Online ChatFacebook MessengerInfopack FormSocial Ad form Please Note: All dates and times are subject to the availability of The Great Care Company. The Great Care Company will aim to meet the times and dates selected by you the user yet cannot guarantee these exact times are met. Once the details of the Care Assessment System have been submitted, a member of the The Great Care Company Support team will be in touch to finalise the details of the Care Assessment CommentsThis field is for validation purposes and should be left unchanged.