Adult social care referral
This form is designed to help you think about your situation and consider what you need support with. It also works as a professional referral form.
Before you start
Before you complete this form, you may find the advice or information you are looking for on these pages:
- Staying independent in your own home
- Somewhere to live
- Getting out and about
- Money matters
- Looking after someone
- Staying safe
- Technology to help you stay independent
What you will need
Before you begin to complete this form, you will need the following:
- A valid email address if you wish to be sent a copy of your completed evaluation, or to save the form as you go along
- If you are completing this form on behalf of someone else, you will need to know their personal details (this includes their address and contact details) and their consent to contact us on their behalf
Notes for professionals
If you have completed your own assessment or report, there is an option to upload relevant documents to your referral. This can be very useful when we process your referral.
Please complete this online referral only and do not send duplicate information or referrals to us via email.
What happens next
Once you submit this form to us, your referral will be processed and passed to the appropriate team to progress. We may contact you to request further information from you or to provide information and advice about the next steps.
Up to: Who we can help
Updated: 10 January 2023