Shared Lives Adult Enquiry Form Adult's name Required the person who wants Shared Lives support Preferred contact number Required If you are filling this in for someone else and want us to contact you, please add your name in brackets after the number Email address Required If you are filling this in for someone else and want us to contact you, please add your name in brackets after the email Adult's postcode Required Postcode Lookup What support are you interested in? Required Long-term accommodation (for adults with a learning disability) Short breaks (respite) (for adults with a learning disability) Day support (for adults with dementia) How did you hear about Shared Lives Stoke? Social media Word of mouth Existing Shared Lives carer Existing Shared Lives adult Internet search Social worker Employment advisor Social prescriber Recruitment event Poster or leaflet