Founding WIDE First Look

Request a founding place.

This short form does not book an appointment or take payment. It helps WIDE understand whether a remote First Look may be an appropriate next step.

Please do not use this form for urgent or rapidly changing symptoms. Contact an appropriate medical service, NHS 111 or emergency care when needed. Do not include a full medical history or confidential documents here.

Your details

Fields marked with an asterisk are required.

Name *

Email *

Phone number

UK town or region *

How would you prefer WIDE to contact you?

The movement or activity

Name one movement or activity. Examples might include bending, turning, reaching, sitting, dressing, gardening or another everyday action.

What movement or activity would you like help with? *

What happens when you try it? * A few sentences are enough. Please do not include attachments or a full medical record.

What would becoming easier make possible for you?

Before you send

I confirm that I am aged 18 or over and currently located in the UK. * I understand that this is not an emergency, diagnostic or work-capacity assessment service. * I agree that WIDE may use the information in this form to contact me about this request. *

Requesting a place does not commit you to treatment or payment. The information will be reviewed first. If a remote First Look appears potentially appropriate, WIDE will send the full details, secure clinical intake and booking options.