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Referral Form

Need Support from Age Cymru West Glamorgan?

You can now refer yourself (or someone you care about) directly using our simple online form.

You can refer yourself for support with things like information and advice, lasting power of attorney, dementia support, footcare, or getting more confident using technology.

Who Can Use This Form?

You, your family, your unpaid carer:
This form is for anyone living in Swansea, Neath, Port Talbot, or Bridgend who would like to access our services or learn more about how we can help.

You can complete it for yourself, or if you’re seeking advice about someone else (like a friend or family member), you should include your own contact details so we can get in touch with you.

For example:
If Mrs Davies wants advice about caring for her dad, Mr Griffiths, she should fill in her own details. That means we’ll contact Mrs Davies — not Mr Griffiths.

Someone can help you fill in the form if you need assistance, but only with your permission and involvement.

Please don’t fill in this form for someone else unless they know about it and are happy for us to contact them.

Professionals Referring a Client:

If you’re a professional (e.g., from a health, care, or community organisation) making a referral, please:

  • Ensure the client is aware of and consents to the referral.
    • Include your own contact details in the form so we can follow up with you if needed.
    • Provide as much detail as possible to help us understand the client’s needs.

What Happens Next?

Once we receive the form, a member of our team will make contact within three working days.

We usually get in touch by phone, but if a different method is preferred, just let us know on the form.During this first contact, we’ll discuss the situation, take a bit more information and work out how we can best provide support.

Your Privacy

By submitting this form, you’re giving us permission to securely store your information and contact you about your referral.

Everything you tell us is treated confidentially. We’ll never share your personal information without your consent.

If you have any questions or need assistance, please call us on 01792 648 866 or email enquiries@agecymruwestglamorgan.org.uk.