Please note that this online referral form should not be used for contacts that require an urgent response. If you require an urgent response please call our contact centre on 020 8726 6500.
Please select one of the following:
Please select from the list all the things that you (the person) is having difficulties with or would like advice or support with:
Please provide details about:
Please provide the details of the allegation of abuse that you are making. Please include:
In order to help us direct your contact to the most appropriate person, please select the disability that has the most impact on your (the person’s) life. If you are a carer making a referral please select the primary disability of the person you care for.
Click here to see more information about sharing information.
Do you give consent to share relevant personal information with other agencies / professionals?
Please tell us about any restrictions you would like to place on sharing your relevant personal information with other agencies / professionals.
If you are making a self-referral, please provide your own name and telephone number
Please provide brief details of equipment to be collected / exchanged / repaired
Please click button to confirm that you have provided all the information you want to tell us. If not, the button will take you to previous pages where you can add more information.
Thank you for submitting your contact referral application.
We will process your contact referral as soon as possible and will contact you or the person concerned to follow up the referral no later than 2 working days.
22 January, 2017
Reason for referral
|Your reason for referral|
Personal details of referrer
|Relationship to person|
|Do you wish your identify to remain confidential?|
Name of person
|Do you know the name of the alleged adult at risk?|
Personal details of referee
|Date of Birth|
|Contact number type|
|Swift number (if known)|
|Do you (the person) live alone?|
|Alias/Likes to be known as|
Awareness of contact
|Is the person aware of the referral / contact being made?|
Reason for contact
|Please select from the list all the things that you (the person) is having difficulties with or would like advice or support with:|
|Disability that has the most impact on your (the person’s) life|
Sharing your information
|Do you give consent to share relevant personal information with other agencies / professionals?|
|Please tell us about any restrictions you would like to place on sharing your relevant personal information with other agencies / professionals|
Collections, exchanges and repairs of equipment
|Date of Birth|
|Alternative contact details|
|Is the client deceased?|
|Are there any risks to staff associated with the inquiry?|
|Brief details of equipment to be collected / exchanged / repaired|