Page 1 of 2

Jakoma Independent Living Tech Enquiry

Need practical support to help an older relative stay safer and more independent at home?
Complete this short form and Jakoma will get back to you to discuss your situation and whether we can help.
Service area: Banbridge + 30 miles. Important: This is a non-clinical service and not an emergency response service.

Contact details

Full Name

Email Address

Organisation

Which best describes your organisation?

Which best describes your organisation?
A
B
C
D
E
F

Phone number

Preferred contact method

Preferred contact method
A
B
C

Best time to contact you

Best time to contact you
A
B
C
D

About the enquiry

Who is this enquiry for?

Who is this enquiry for?
A
B
C
D
E

What town or postcode is the property in?

Is the property within Banbridge + 30 miles?

Is the property within Banbridge + 30 miles?
A
B
C

Main concerns

What are the main concerns?

What are the main concerns?
A
B
C
D
E
F
G
H
I
J

Please briefly describe the situation

Home setup

Is broadband available in the property?

Is broadband available in the property?
A
B
C

Is there working Wi-Fi in the home?

Is there working Wi-Fi in the home?
A
B
C

Are cameras acceptable if appropriate for the setup?

Are cameras acceptable if appropriate for the setup?
A
B
C
D

Next step

What are you hoping for help with?

What are you hoping for help with?
A
B
C
D
E

How did you hear about Jakoma?

How did you hear about Jakoma?
A
B
C
D
E
F
G

Anything else we should know?

Consent checkbox

Consent checkbox