Professional Referral

Full name (required)

House number and street name (required)

Postcode (required)

Telephone number

Date of birth (required)

NHS Number (if known)

Please confirm this person is aware that their details are being shared with Care Network (we will only be able to contact this person if you indicate ’yes’ below)

Yes

Name

Relationship

Telephone number

Name of referrer (required)

Team (required)

Telephone number (Referrer) (required)

Email address (Referrer) (required)

Consent to share information (required)

The above named customer has given consent for their personal information to be shared with Care Network so that they can be provided with appropriate options to support their health, wellbeing and independence

Please select the customer’s needs from the options below

Needs help to manage a long term health condition / sensory impairmentHas recently had a fall/ is afraid of fallingNeeds a Healthy Homes assessment to identify and reduce the environmental hazards that increase the risk of fallingNeeds access to the Safe Trader Scheme for home repairs / DIYIs struggling to keep the house warm/ pay fuel billsNeeds help to manage a low income/ has debt issuesNeeds a fire safety check/ smoke alarmWants or needs to move homeHas an illness or disability or supports/cares for someone who doesFeels lonely or isolatedNeeds assistance to live a healthier lifestyle e.g. stop smoking/ alcohol or substance issues/ exercise/ weight managementNeeds support to live independently e.g. shopping/ foot care/ meals/ gardening etc – please give brief details belowIs recently bereavedNeeds information or support to access health & social care servicesWants to work/ discuss employment options / volunteer / access training and learningNeeds transport adviceHas a learning disability autism, memory loss or dementia or supports/cares for someone who doesWould like to know more about living with memory loss or dementia

Brief overview of situation (to be completed for all referrals) (required)

Is there any reason why this person (the referred) should not be visited at home by a single member of staff? If you select yes we will be in touch with you for further details (required)

Is the outcome of this referral likely to prevent a hospital admission? (required)

Is the outcome of this referral likely to prevent or delay the need for domiciliary care? (required)

Is the outcome of this referral likely to prevent or delay the need for residential care? (required)

The information you enter into this form will be collected and stored by Care Network and used to contact the customer / alternative contact regarding this referral. (required)

Please confirm that the customer understands this and has been directed to Care Network’s Privacy Notice which can be found at www.carenetwork.org.uk/privacy-notice

Please tick the box below if the customer would like a paper copy of our Privacy Notice posted to them

Please post a paper copy of Care Network’s Privacy Notiice

Professional Referral

Customer information

Next of Kin / Alternative contact

Referrer’s details