Adult Social Care referral form
What is this form for?
This referral form is for members of the public who are finding it difficult to look after themselves or manage daily tasks. This form is also for professionals working with adults.
What is this form not for?
This form is not for urgent requests – please call 999 if you urgently need medical attention.
What does this form contain?
This form contains questions around your current situation and condition, as well as services and resources that you have used up to this point. As well as this, it asks about any future aspirations you have.
Before you complete this form it is important to make sure that you have explored the other options for support. Ensure you have:
- Spoken to friends and family to see what support they can offer
- Reviewed the directory of support services for activities and organisations which support your independence
- Looked for tools and equipment to support you from EquipMe
EquipMe
Make life easier in three simple steps with EquipMe, get impartial advice about tools and equipment to make daily living easier:
- Choose a topic
- Answer some questions
- Get advice
Are you a professional?
Professionals using the following form should also include the following information, where applicable:
- If you are a care provider, please upload copies of care plans or logs from within the last two weeks
- If you are a residential care provider and looking for an adult to move into nursing care, please provide copies of nursing assessments and a 72 hour behaviour chart
- If you are from another local authority, please upload copies of any assessments you have done, or any information about any commissioned services you are funding of have funded
- You can also upload a completed document about the adult
- If you have any home access visit reports, please provide them
- If you have been referred from the Community Independence Service (CIS), please provide a copy of any housing adaptations forms
- For the return of equipment, or repair or replacement of faulty equipment, please contact NRS Healthcare Equipment Stores: Customer Services at 03332 408 335
- For wheelchair-related inquiries, contact your client's GP to facilitate a referral to wheelchair services
Before you fill in this form
This form will take at least 15 minutes to complete. Please allow enough time to complete it in one sitting as the form cannot be saved and completed later.
This form is the fastest method in which to make a referral to the council for additional support.
