## Do you need extra help?

Complete the short form below, and a member of our team will be in touch.

For more information, please see our [vulnerability leaflet](https://www.veolia.co.uk/sites/g/files/dvc1681/files/document/2026/03/vulnerability_vwpl_-_mkt0001979_a5_leaflet_v1.pdf).



 

 

 



[Do you qualify for Watersure?](https://www.veolia.co.uk/help-pay-your-bill)

 



 

 

 



 

 

 

 





 

 You must have JavaScript enabled to use this form.

 ### Your Details

 Name:  

 

 

 Phone number:  

 

 

 Email:  

 

 

 Address:  

 





 Postcode:  

 







 

 

 

  



 ### Vulnerability section



 

 Age, if you: - None -are of a pensionable agehave children under the age of five. 

 

 

 Communication, if you: - None -are blind or partially sightedare unable to communicate in Englishhave a hearing impairment or are deafhave a speech impairmenthave a developmental condition, eg, autism, Asperger’s or dyslexia 

 

 

 Medical conditions, if you: - None -have a chronic or serious illnessare medically dependent on showering or bathinghave a mental health conditionneed a constant supply of water (water dependent)have a cognitive impairment, including dementia. 

 

 

 Medical equipment, if you use a: - None -nebuliser or sleep apnoea monitorheart or lung ventilatordialysis machine, feeding pump or automated medicationstair lift, hoist or electric bedoxygen concentrator or require oxygen therapycareline/telecare systemmedicine refrigerator. 

 

 

 Mobility, if you: - None -have a physical impairmentare unable to answer the doorhave restricted hand movement. 

 

 

 Safety, if you: - None -have a poor sense of taste or smellwould like additional presence when we visit you 

 

 

 A temporary change, if you: - None -are going through a significant life change such as bereavement or divorce, losing your job or being unable to cope with everyday lifeare a young adult householder (under 18)are recovering after being in hospital. 

 

 

 Other Potential Vulnerabilities 

 

 

 

 

 

  



 ## Action

   

  

 

 

By completing this form, you give your consent to the collection and use of the personal data that concern you.  
[Read all the disclaimer.](https://www.veolia.com/en/form-disclaimer)