First name

Last name

Email

Phone number

Postcode

To access this service, you must:

• Be in permanent or temporary employment.

• Have a mental health condition (diagnosed or undiagnosed) that has resulted in workplace absence or is causing difficulties to remain in work.

Please tick this box to confirm you meet the criteria

If you're not sure or would like to refer yourself by telephone, call our friendly team on 0300 456 8114.

Please tell us more about how you would like Remploy to support you:

By providing this data you are giving consent to the Access to Work Mental Health Support Service team to contact you from time to time about developments with the service and other information that we think will be of interest to you. You can unsubscribe from this contact list at any time. Your personal information is important to us and will, under no circumstances, be shared with any other third party for marketing purposes. By submitting this enquiry form you are confirming that you have read and agree to our Privacy Policy.