MS Society self-referral form

Funded by the Nottingham Branch of the MS Society, we provide a benefits advice service to clients with MS and their immediate carers, providing information, advice and support to enable individuals to claim all benefits they are entitled to. For non-benefits related advice, we can signpost and refer clients either internally or to other agencies.

This service is available to people who have Multiple Sclerosis or their carers who reside in the Nottingham MS Society branch area which includes South Nottinghamshire and Long Eaton. If you complete this webform and you do not meet this criteria, you will be directed to another method of accessing advice from Citizens Advice Nottingham.

Title

First name (required)

Last name (required)

Address

Postcode

Your email address

Daytime telephone number

By providing a telephone number, you consent to us calling you.

Mobile number

By providing a mobile number, you consent to us calling you.

Disability/health problems (We need your explicit consent to record your disability. If you do NOT agree to this please select Prefer not to say.)

What can we help you with? If relevant, please provide dates or deadlines.

Would you prefer a face to face appointment?

By submitting your enquiry you are confirming that you
• Have Multiple Sclerosis or care for someone with Multiple Sclerosis
• Live in the South Nottinghamshire or Long Eaton area
• Consent to us recording and retaining the details you provide in this form.