Support Broker

Your Details

Your Name*

Your trading name/organisation name, if you have one

Email*

Telephone Number/s:*

Address*

What are your areas of knowledge and experience?
Acquired Brain InjuryAssistive TechnologyAutism/SensoryBenefitsChildren and Young People (EHC/SEND/Transition)0 - 8 years8 - 15 years16 - 25 yearsCommunicationCommunity ConnectingDementiaEnd of Life CareEquipmentHousingLearning DisabilityLegal (Health and Social Care/Public Law)Long Term Health ConditionsMental Health Act (CPA Section 117 Guardianship CTO)Micro Providers/Personal AssistantsPerson Centred Complex Problem SolvingPerson Centred PlanningPerson Health Budgets with CCGsPhysical DisabilityTechnologyTransforming CareVision Planning/Graphic FacilitationVisual and Hearing Impairment

Do you have any other areas of knowledge and experience?

To complete this process – you will need to provide the following details: a copy of your current DBS check / evidence that you are registered with the online service and insurance document copies (if any).

It is essential that we have this information to be able to process your membership application. We will not be able to refer you unless we have your valid DBS information. See DBS online account guidance here.

If you have a hardcopy:
A photo of your enhanced DBS check certificate number
We do not need to see the whole document just the DBS number.

Your date of birth:
Please type the relevant date in the format of dd/mm/yyyy

Surname on the certificate:

For Online service:
Please tick this box if you are registered for the Online Service

Copy of insurance documents (if you are a freelance support broker)

Would you like your profile details adding to the NBN directory on our website?*
YesNo

The information you provide in the following section is mandatory for our purposes, but will of course only appear on our website if you have selected "Yes" to the above question.

Please be aware, if you do choose to appear on the directory but do not answer the section below it will appear blank on your profile on our website directory so please fill out as much as you can.

We will be asking you about your DBS status again, the information you provide here will feature on the website.

The contact details you have provided at the top of the form will not be shown on the website. We will facilitate the referral and connections once someone has selected a Support Broker from our online Support Broker directory.

Location:*

Areas covered:*
Please be aware if you select 'All Areas of England' your profile will only show up on our website directory if our website visitors select 'All Areas of England' to filter their directory search. You won't come up if they select individual areas in England, i.e Bolton.' If you would like to appear in individual areas when website visitors select them to filter their search please select all the areas you cover from the list below.
On a computer if you wish to select multiple areas, click on an area so it is highlighted in blue, then hold down 'Ctrl' on your keyboard and use the downward arrow on the scrolling bar or the downward arrow on your keyboard to scroll down and select other areas by clicking them so they go blue too. Once you click out of the box the areas you've selected will be highlighted in grey. Use your mouse to select relevant areas, please don't try typing.
On a mobile or tablet, simply tap the areas you wish to select.

- All areas of the UK- All areas of England- All areas of Wales- All areas of ScotlandAberdeen CityAberdeenshireAdurAllerdaleAmber ValleyAngusAntrim and NewtownabbeyArds and North DownArgyll and ButeArmagh City, Banbridge and CraigavonArunAshfieldAshfordAylesbury ValeBaberghBarnetBarnsleyBarrow-in-FurnesBasildonBasingstoke and DeaneBassetlawBath and North East SomersetBedfordBelfastBexleyBirminghamBlabyBlackburn with DarwenBlackpoolBlaenau GwentBolsoverBoltonBostonBournemouthBracknell ForestBradfordBraintreeBrecklandBrent Barking and DagenhamBrentwoodBridgendBrighton and HoveBroadlandBromleyBromsgroveBroxbourneBroxtoweBurnleyBuryCaerphillyCalderdaleCambridgeCamdenCannock ChaseCanterburyCardiffCarlisleCarmarthenshireCastle PointCauseway Coast and GlensCentral BedfordshireCeredigionCharnwoodChelmsfordCheltenhamCherwellCheshire EastCheshire West and ChesterChesterfieldChichesterChilternChorleyChristchurchCity of BristolCity of EdinburghCity of Kingston upon HullCity of LondonClackmannanshireColchesterConwyCopelandCorbyCornwallCotswoldCounty DurhamCounty of HerefordshireCoventryCravenCrawleyCroydonDacorumDarlingtonDartfordDaventryDenbighshireDerbyDerbyshire DalesDerry City and StrabaneDoncasterDoverDudleyDumfries and GallowayDundee CityEalingEast AyrshireEast CambridgeshireEast DevonEast DorsetEast DunbartonshireEast HampshireEast HertfordshireEast LindseyEast LothianEast NorthamptonshireEast RenfrewshireEast Riding of YorkshireEast StaffordshireEastleighElmbridgeEnfifieldEpping ForestEpsom and EwellErewashExeterFalkirkFarehamFenlandFermanagh and OmaghFifeFlintshireForest HeathForest of DeanFyldeGatesheadGedlingGlasgow CityGloucesterGosportGraveshamGreat YarmouthGreenwichGuildfordGwyneddHackneyHaltonHambletonHammersmith and FulhamHarboroughHaringeyHarlowHarrogateHarrowHartHartlepoolHastingsHavantHaveringHertsmereHigh PeakHighlandHillingdonHinckley and BosworthHorshamHounslowHuntingdonshireHyndburnInverclydeIpswichIsle of AngleseyIsle of WightIsles of ScillyIslingtonKensington and ChelseaKetteringKing's Lynn and West NorfolkKingston upon ThamesKirkleesKnowsleyLambethLancasterLeedsLeicesterLewesLewishamLichfifieldLincolnLisburn and CastlereaghLiverpoolLutonMaidstoneMaldonMalvern HillsManchesterMansfieldMedwayMeltonMendipMerthyr TydfilMertonMid and East AntrimMid DevonMid SuffffolkMid SussexMid UlsterMiddlesbroughMidlothianMilton KeynesMole ValleyMonmouthshireMorayNa h-Eileanan SiarNeath Port TalbotNew ForestNewark and SherwoodNewcastle upon TyneNewcastle-under-LymeNewhamNewportNewry, Mourne and DownNorth AyrshireNorth DevonNorth DorsetNorth East DerbyshireNorth East LincolnshireNorth HertfordshireNorth KestevenNorth LanarkshireNorth LincolnshireNorth NorfolkNorth SomersetNorth TynesideNorth WarwickshireNorth West LeicestershireNorthamptonNorthumberlandNorwichNottinghamNuneaton and BedworthOadby and WigstonOldhamOxfordPembrokeshirePendlePerth and KinrossPeterboroughPlymouthPoolePortsmouthPowysPrestonPurbeckReadingRedbridgeRedcar and ClevelandRedditchReigate and BansteadRenfrewshireRhondda Cynon TafRibble ValleyRichmond upon ThamesRichmondshireRochdaleRochfordRossendaleRotherRotherhamRugbyRunnymedeRushcliffeRushmoorRutlandRyedaleSalfordSandwellScarboroughScottish BordersSedgemoorSeftonSelbySevenoaksSheffieldShepwayShropshireSloughSolihullSouth AyrshireSouth BucksSouth CambridgeshireSouth DerbyshireSouth GloucestershireSouth HamsSouth HollandSouth KestevenSouth LakelandSouth LanarkshireSouth NorfolkSouth NorthamptonshireSouth OxfordshireSouth RibbleSouth SomersetSouth StaffordshireSouth TynesideSouthamptonSouthwarkSpelthorneSt AlbansSt EdmundsburySt. HelensStaffordStaffordshire MoorlandsStevenageStirlingStockportStockton-on-TeesStoke-on-TrentStratford-on-AvonStroudSuffolk CoastalSunderlandSurrey HeathSuttonSwaleSwanseaSwindonTamesideTamworthTandridgeTaunton DeaneTeignbridgeTelford and WrekinTendringTest ValleyTewkesburyThanetThree RiversThurrock Southend-on-SeaTonbridge and MallingTorbayTorfaenTorridgeTower HamletsTraffordTunbridge WellsUttlesfordVale of GlamorganVale of White HorseWakefieldWalsallWaltham ForestWandsworthWarringtonWarwickWatfordWaveneyWaverleyWealdenWellingboroughWelwyn HatfieldWest BerkshireWest DevonWest DorsetWest DunbartonshireWest LancashireWest LindseyWest LothianWest OxfordshireWest SomersetWestminsterWeymouth and PortlandWiganWiltshireWinchesterWindsor and MaidenheadWirralWokingWokinghamWolverhamptonWorcesterWorthingWrexhamWychavonWycombeWyreWyre ForestYork

Photo of yourself:
Maximum file size is 2MB. Photo must be at least 800px by 800px.

Your interests:*

Support Brokerage Trained?*
YesNo

Are you accredited?*
YesNo

State the year you trained as a Support Broker.*

Who trained you?*

Other relevant qualifications you hold: Please provide Course title, date received and training provider e.g. Occupational therapy, British Sign Language.

Are you independent?*
YesNo

Are you working within an organisation or self-employed? Please provide details*
OrganisationSelf-employed

Current Enhanced DBS? (less than 2 years old)*
YesNo

Registered for the online DBS Check Service*
YesNo

Do you receive mentoring?*
YesNo

What insurance do you have in place?*
Public LiabilityProfessional Indemnity

Are References Available?*
YesNo

The functions you provide as a Support Broker

Please select "Yes" or "No" to the following questions.

Service Design: Are you able to design and develop individually tailored support packages?*
YesNo

Payroll Service: Are you able to organise pay and taxation for people employing their own supporters?*
YesNo

Accounting: Are you able to help people keep up-to-date financial records and returns for their personal budget?*
YesNo

Recruitment: Are you able to help people recruit their own supporters?*
YesNo

Personnel Advice: Are you able to offer personnel advice to people managing their own support?*
YesNo

Community Development: Are you able to help people to make connections within their community?*
YesNo

Benefits and Funding Advice: Are you able to help people identify and claim additional benefits, entitlements or possible resources?*
YesNo

Do you provide have any other functions that are not listed above?

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NBN Consent Form

As a Member of Imagineer/Support Brokerage Network, it is important we ask you about your contact preferences and what information you want to receive.

We need to ensure that you are happy with us keeping your details so that we can contact you with information about our activities and find out about what we are doing.

To help Imagineer/Support Brokerage Network meet the data protection regulations we need to find out if you are happy for us to store your data – in accordance with GDPR.

Please complete your details and contact preferences below.

Date Completed*
Please type the relevant date in the format of dd/mm/yyyy

How would you prefer to be contacted? (You choose can more than one)*
EmailPostSMS Text MessageTelephone LandlineTelephone Mobile

I want to:*
Receive Imagineer's/Support Brokerage Network - News and UpdatesReceive Information about Imagineer's/Support Brokerage Network events that I attendReceive information about additional Imagineer's/Support Brokerage Network events

Subscribe to our mailing list?*
yesno

Consent: (please tick if you agree)*
I confirm that I consent to Imagineer Development UK CIC and the Support Brokerage Network subcommittee keeping my information stored for the purposes of fulfilling their commitment to me as one of their members
I am aware that I can retract this consent at anytime and I can do this by contacting Imagineer Development UK CIC by phone, email or letter to retract this consent. At which stage any information stored about be will be deleted and / or destroyed appropriately

To Opt Out In Future:

You can opt-out of receiving information from Imagineer at any time by writing to or emailing Imagineer via email: info@imagineer.org.uk / Post: Imagineer Development UK CIC, Sowerby Bridge Fire & Water, Sowerby Bridge HX6 2QG. Telephone: 07572322200.

We take your data security seriously and will never sell or swap your details with third parties. You can withdraw your consent for Imagineer to store your data at any time by calling 07572322200 or emailing info@imagineer.org.uk. Information about how we protect and use your personal data is set out in our Data Protection Policy which we can send you a copy if you wish to see this.

If you require having access to the personal information Imagineer has stored about you please could you request this in writing to Imagineer Development UK CIC, Sowerby Bridge Fire & Water, Sowerby Bridge HX6 2QG.

If at any time we have made an error with your personal details – please tell us!
We will then rectify the error on our systems – then inform you in writing.

Please leave this field empty.

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