Device Request Form

Digital Referral Form (July 24 - Dec 24)

Please complete this form to request a device for yourself or on behalf of someone you are supporting, if you are referring yourself please populate n/a into all answers in section 1 (please note criteria has changed from previous project)

Digital EXT (July 24 - Dec 24) - This project is to support citizen's of Moray with accessing digital health and social care by reducing barriers and creating confidence through training and support. For more information or to have a discussion with a member of the team please email: hello@moraywellbeinghub.org.uk

Please note device distribution is a small element of this project and we have limited funds and can not guarantee your preferred choice, we can not supply multiple devices to one beneficiary this is for people who face a digital barrier and have no form of access.

Section 1 - Your Own Details

Please enter your own details in this section.

1. Name of person completing form:

2. Organisation of person completing the form:

3. Email address of person completing the form:

4. Phone number of person completing the form:

Section 2 - Beneficiary details

Please enter the details of the person you're referring (the beneficiary).

5. Name of beneficiary:

6. Email of beneficiary:

7. Postcode of beneficiary:

8. Phone number of beneficiary:

9. Are you a Moray Wellbeing Hub champion?

If you'd like to learn more about becoming a Moray Wellbeing Hub champion, please click here.

Section 3 - Understanding device and connectivity distribution remit

Our current remit for supplying devices and connectivity is that the supply will:

Support the beneficiary to access health and social care services
The beneficiary is willing to reconnect in 4 weeks (approximately) for feedback this is a funder requirement
Be issued if we have sufficient supplies (small number of devices available for those who need support accessing health and social care services)
If a local partner can not supply a more appropriate support of device
The beneficiary lives in Moray and could not otherwise access a device for financial reasons (we do not means test)

10. I understand the above information numbered 1 - 5 for device and connectivity distribution?

11. I meet the below criteria (You may select more than one category):

12. I am hopeful to receive (you may select more than one answer):

13. Do you currently have internet at your home?

Internet access could be fixed line broadband from companies like BT, Vodafone, Sky etc, satellite broadband like Starlink, or a personal hotspot from a Smart Phone or MiFi device.

14. What technology do you or have you used in the past, if any?

This question allows us to gain knowledge or support or device requirement.

15. How easy/difficult did you find using these devices in the past?

Please let us know about your experiences with the devices you currently have or have used in the past.

Do you/did you find them easy/difficult to use?

How often do you/did you use these devices, and was there any type of device you preferred?

What worked well for you or could have been better?

16. What do you use or intend to use your device for? Please ensure you include a form of accessing health and social care services and support and training will be provided as part of the projects outcomes?

Examples could be keeping in contact with friends and family, doctors, accessing mental health services online.

17. Where will you/do you primarily use the device?:

Will you be using the device primarily at home, or travelling or at work?

18. If you are requesting a device or connectivity please indicate your preference into the below box (this is not guaranteed)?:

19. What further technical support do you require?

If you do, please detail what support you'd like.