Contact Referrals

Reason for referral

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 choose reason for contact

Personal details of referrer

Full name is required
Email is required Email is not valid
Telephone number is not valid
This field is required
This field is required

Name of person

This field is required

Personal details of referee

Title is required
First name is required
Last name is required
Email is required Email is not valid
Date of birth is required
Telephone number is not valid
Please select an option
This field is required
This field is required
This field is required
This field is required

Awareness of contact

This field is required

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:

Please provide details about:

  • Why you are contacting adult social care?
  • The difficulties that you (the person) is having
  • How you think we can help?
  • Any relevant disabilities or diagnoses of the adult at risk
  • Any communication needs of the adult at risk, including language or sensory impairments

Please provide the details of the allegation of abuse that you are making. Please include:

  • The name of the alleged adult at risk (if known)
  • Any disabilities or diagnoses that you know the alleged adult at risk has
  • Where the alleged victim is now and whether they are safe
  • The name of the alleged person or organisation causing harm
  • A description of the abuse, including where and when it happened
  • Whether you are certain this abuse has taken place or is it a suspicion / concern you have
  • Whether you think a crime has been committed, and if yes, if the police are aware
  • Whether you have told or reported this matter to anyone else (e.g. CQC, service provider, etc)
Please provide the details about why you are contacting adult social care

Primary disability

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.

Please choose an option

Sharing your information

Click here to see more information about sharing information.

Do you give consent to share relevant personal information with other agencies / professionals?

Please choose an option

Please tell us about any restrictions you would like to place on sharing your relevant personal information with other agencies / professionals.

Please tell us about any restrictions

Collections, exchanges and repairs of equipment

Client information:

Title is required
First name is required
Last name is required
Date of birth is required
Telephone number is not valid
This field is required
This field is required

Referrer details:

If you are making a self-referral, please provide your own name and telephone number

Name is required
Telephone number is required Telephone number is not valid

Please provide brief details of equipment to be collected / exchanged / repaired

Please provide brief details

Application summary

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.

Reason for referral

{{enums.reasonForReferral[wizardObj.model.ReasonForReferral.Reason-1].name}}

Personal details of referrer

{{wizardObj.model.DetailsOfReferrer.FullName || "-"}}
{{wizardObj.model.DetailsOfReferrer.Email || "-"}}
{{wizardObj.model.DetailsOfReferrer.Telephone || "-"}}
{{wizardObj.model.DetailsOfReferrer.Relationship || "-"}}
{{wizardObj.model.DetailsOfReferrer.IdentifyConfidential || "-"}}

Name of person

{{wizardObj.model.NameOfPerson.AllegedAdultAtRisk || "-"}}

Personal details of referee

{{wizardObj.model.PersonalDetails.Title || "-"}}
{{wizardObj.model.PersonalDetails.FirstName || "-"}}
{{wizardObj.model.PersonalDetails.LastName || "-"}}
{{wizardObj.model.PersonalDetails.Email || "-"}}
{{wizardObj.model.PersonalDetails.DateOfBirth || "-"}}
{{wizardObj.model.PersonalDetails.Address.PostCode || "-"}}
{{wizardObj.model.PersonalDetails.Address.AddressLine1 || "-"}}
{{wizardObj.model.PersonalDetails.Address.AddressLine2 || "-"}}
{{wizardObj.model.PersonalDetails.Address.City || "-"}}
{{wizardObj.model.PersonalDetails.Telephone || "-"}}
{{wizardObj.model.PersonalDetails.ContactNumberType || "-"}}
{{wizardObj.model.PersonalDetails.SwiftNumber || "-"}}
{{wizardObj.model.PersonalDetails.LiveAlone || "-"}}
{{wizardObj.model.PersonalDetails.KnownAs || "-"}}
{{wizardObj.model.PersonalDetails.Gender || "-"}}
{{wizardObj.model.PersonalDetails.Nationality || "-"}}
{{wizardObj.model.PersonalDetails.Ethnicity || "-"}}

Awareness of contact

{{wizardObj.model.AwarenessOfContact.AwareOfTheReferral || "-"}}

Reason for contact

{{wizardObj.model.ReasonForContact.Details || "-"}}

Primary disability

{{wizardObj.model.PrimaryDisability.PersonYouCare || "-"}}

Sharing your information

{{wizardObj.model.SharingYourInformation.SharePersonalInformation || "-"}}
{{wizardObj.model.SharingYourInformation.Details || "-"}}

Collections, exchanges and repairs of equipment

Client information:

{{wizardObj.model.CollectionsExchangesAndRepairsOfEquipment.Title || "-"}}
{{wizardObj.model.CollectionsExchangesAndRepairsOfEquipment.FirstName || "-"}}
{{wizardObj.model.CollectionsExchangesAndRepairsOfEquipment.LastName || "-"}}
{{wizardObj.model.CollectionsExchangesAndRepairsOfEquipment.Address.PostCode || "-"}}
{{wizardObj.model.CollectionsExchangesAndRepairsOfEquipment.Address.AddressLine1 || "-"}}
{{wizardObj.model.CollectionsExchangesAndRepairsOfEquipment.Address.AddressLine2 || "-"}}
{{wizardObj.model.CollectionsExchangesAndRepairsOfEquipment.Address.City || "-"}}
{{wizardObj.model.CollectionsExchangesAndRepairsOfEquipment.DateOfBirth || "-"}}
{{wizardObj.model.CollectionsExchangesAndRepairsOfEquipment.AlternativeContactDetails || "-"}}
{{wizardObj.model.CollectionsExchangesAndRepairsOfEquipment.Telephone || "-"}}
{{wizardObj.model.CollectionsExchangesAndRepairsOfEquipment.ClientDeceased || "-"}}
{{wizardObj.model.CollectionsExchangesAndRepairsOfEquipment.AnyRisksToStaffAssociated || "-"}}

Referrer details:

{{wizardObj.model.CollectionsExchangesAndRepairsOfEquipment.SelfReferralName || "-"}}
{{wizardObj.model.CollectionsExchangesAndRepairsOfEquipment.SelfReferralTelephone || "-"}}
{{wizardObj.model.CollectionsExchangesAndRepairsOfEquipment.Details || "-"}}

Application completed

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.

Return to Home Page

Contact Referral

24 April, 2017

 

Reason for referral

Your reason for referral

Personal details of referrer

Full name
Email address
Telephone
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

Title
First Name
Last Name
Email
Date of Birth
Post code
Address line1
Address line2
City
Telephone
Contact number type
Swift number (if known)
Do you (the person) live alone?
Alias/Likes to be known as
Gender
Nationality
Ethnicity

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:
Details

Primary disability

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

Title
First name
Last name
Post code
Address line1
Address line2
City
Date of Birth
Alternative contact details
Telephone
Is the client deceased?
Are there any risks to staff associated with the inquiry?
Referrer name
Referrer telephone
Brief details of equipment to be collected / exchanged / repaired

How do you rate this page?

Loading