Great Prospects Care Services
Quick Referral Form

Quick Referral Form

    Access Service and Independent Living Resource Centre Standard Referral Form

    Only Use this form for Adult Social Care Services (age 18+).

    All fields are mandatory

    Client Details
    Title*: Other:
    Forename(s)*: Surname*:
    NHS Number*: Date of Birth (DD/MM/YYYY)*:
    House Number/House Name*: Street Name*:
    Town/City*: County*:
    Postcode*: Contact Number*:
    Other Telephone Number: Email Address:
    Tenure: Owner OccupiedPrivate RentedCouncilHousing AssociationSheltered AccommodationResidential/Nursing Home
    Other Tenure:
     

    GP Details
    GP Surgery: Name of GP:
    GP Telephone: GP Address:
     

    Next of Kin Details
    Name: Telephone:
    Mobile: Address:
     

    Reason for Referral
    HealthPersonal CareMobility IssuesNeglectSocial IsolationFallsMain carer unable to continue in their caring roleSupport with daily living tasks (please list):

    The following sections of this Self Assessment will assist us in determining the correct level of support you may require to meet your needs. Please complete as many of the following questions as possible and use each text area if you wish to provide us with further information.
    Other – please describe:
     

    Communication Needs

    Hearing ImpairmentInterpreter required
    Other, please state:
     

    Safeguarding Issues

     
    YesNo
    If yes, please describe:
     

    Other Issues

     

    Medical Information

    (e.g. Arthritis – hips and knees affected, diabetes, COPD, etc)

    Medication

    List current medication

    Identified Need / Current Difficulty

    (please describe e.g. difficulty accessing the bath, stair mobility, personal care tasks)

    Please enter on scale 1 – 5

    1. Independent, no difficulty
    2. Independent with equipment
    3. Independent with difficulty
    4. Dependent on assistance
    5. Unable to carry out
    		(Please note: Issues requiring mobility aids – walking sticks, frames, trolleys – should be referred via GP to the Physiotherapy department for a mobility assessment)
    Functional Ability (Please enter on scale 1 – 5 – see right)
    Chair / settee ↓ Bed ↓ Toilet ↓ Stairs ↓
    Mobility ↓ Bath/Shower ↓ Personal Care ↓
     
    Any further relevant information? (Attends a day centre on Mondays)
     
    Referrer Details
    Name*
    Email Address*:
    Address*:
    Postcode*:
    Telephone*:
     
    Is service user/patient aware of referral? YesNo
    If yes, do they consent to the sharing of information with other health organisations? YesNo