SUFFERING FROM INCONTINENCE?

Please answer questions below to send the referral form to your local authority. The local authority will contact you within 2 to 5 days to make an appointment.

Do you sometimes struggle with getting to the toilet on time/suffer with incontinence?
Yes No
Do you use a commode?
Yes No
Do you use any equipment to help you in the toilet?
Yes No
Are you concerned about getting pressure sores?
Yes No
Can you turn a light on from your bedroom?
Yes No
When going to the toilet at night - do you need the light?
Yes No
Do you have difficulty using a toilet in a public place?
Yes No
Do you receive any homecare?
Yes No
Are you seeing an Occupational Therapist or Another Service?
Yes No
Are you concerned about any other risks?
Yes No