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Welcome

Lifeline is an emergency community alarm service that provides users with an additional level of security so that they can continue to live independently in their own home. To find out more about how the Lifeline Service works, the equipment available, and costs involved please click here (hyperlink to lifeline brochure).

For installation the Lifeline unit requires both a landline socket and an electrical plug socket on the same wall (within 3 metres of each other). Please make sure your home meets these requirements before completing the online application.

About You

Are you completing this form on behalf of yourself?

Your details

Please tick the box which best describes you:
Please select best description.

Your Details

Please tick the box which best describes the person you are referring:
Please select best description.

Current Circumstances

To understand which Lifeline equipment/services are best suited to you we need some more information.

Are you or the person you are referring already a Lifeline user?

Please answer YES or NO to the following questions. If you are completing this form on behalf of somebody else please direct the questions to them.

1. Have you experienced any falls within the last 3 months?
2. Do you find it difficult to use small buttons? For example, the buttons on a telephone or T.V. remote control?
3. Have you experienced problems with your short-term memory in the last 3 months? For example, do you find yourself leaving your cooker on or your taps running?
4. Is there an increased risk of fire within your home? For example, due to smoking or hoarding?
5. Would you be able to respond appropriately in the event of a fire in your home?

Applicants Details'

First Resident Information

Second Resident Information

Applicants Details'

Address Information

Address Details not found.

Access / Equipment Information

Is there a key safe fitted?

Resident Contact 1

Your resident contact should be someone you know, that lives nearby and is willing to be contacted by telephone (landline and/or mobile) in an emergency to provide assistance.

Key Holder?
Next Of Kin?

Address Details not found.

Resident Contact 2

Your resident contact should be someone you know, that lives nearby and is willing to be contacted by telephone (landline and/or mobile) in an emergency to provide assistance.

Key Holder?
Next Of Kin?

Address Details not found.

Resident Contact 3

Your resident contact should be someone you know, that lives nearby and is willing to be contacted by telephone (landline and/or mobile) in an emergency to provide assistance.

Key Holder?
Next Of Kin?

Address Details not found.

Consent

I confirm that the persons named as emergency contacts, keyholders and doctors are aware that they have been named and that they agree with their name and contact details being stored and used by Dacorum Borough Council and Tunstall Response for this purpose.

Privacy Statement

The information you give us will be held on council systems with appropriate security and access. The information we collect will be used for the purpose of setting up, monitoring and providing a community alarm service to enable you to summon help if needed. We may need to share this information with external health and social care professional’s/providers who from time to time need to consult, in order to advise or provide you with the appropriate services.

Optional: We would also like to use your information for service planning, monitoring services and research. We will only do this if you tick YES below. If you do not wish for us to use your details for this purpose please tick NO.

Thank You

Thank you for completing the Lifeline and Telecare Service Online application form. A member of the team will contact you within 5 working days.

In the meantime, if you have any questions or would like to discuss the Lifeline Service further please get in touch. Your reference is

Email: Lifeline@dacorum.gov.uk
Telephone: 01442 228 347



More information on how the council use your personal data can be found here; www.dacorum.gov.uk/privacypolicies