Self Referral Form

If you need support from Age Cymru West Glamorgan, you can now refer yourself 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?

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 fill in this form for yourself, or if you're looking for advice about someone else (like a friend or family member), that’s absolutely fine too — just make sure to put your own contact details in the form. That way, we can get in touch with you to offer support or guidance.

For example:

If Mrs Davies wants advice about caring for her Dad, Mr Griffiths, she should fill in her own details on the form. That means we’ll contact Mrs Davies to offer advice — not Mr Griffiths.

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

Please don’t fill in this form on behalf of someone else unless they know about it and are happy for us to get in touch.

What Happens Next?

Once we receive your form, one of our team members will contact you within two working days.

We’ll usually get in touch by phone, but if you'd prefer to be contacted in a different way, just let us know when you fill in the form.

During the call, we’ll talk through your needs and work out how we can best support you.

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.