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1. Full name*
2. Addresssnippet
  1. Address lookup
    
    Postcode
    
    Address
  3. Your address*
3. Telephone number*
4. Email address*
5. What type of placements are you interested in?
  
  Long term placements
  
  Short term breaks
  
  No preference
  Long term placements are also known as permanent placements. This is where the person lives in your home on a long-term basis. Short term breaks can be for one night to a number of weeks. Short term breaks can be one off or on a regular basis.
6. Which group of people do you want to support?
  
  People with a learning disability
  
  Older adults
  
  People with physical disabilities
  
  People with mental health issues
  
  No preference
7. Where did you hear about Shared Lives?*
8. Other, please specify
9. Has anybody recommended Shared Lives to you?*
  
  Yes
  
  No
10. If yes, who? (family member, neighbour, Council worker)
11. Are they currently a Shared Lives carer?
  
  Yes
  
  No
12. Additional comments
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