Adult Care referral form for public

What this form is for 

This form is for members of the public who are having difficulty looking after themselves or managing day-to-day activities. 

How this form can help you

You'll share some details about your situation, and we'll connect you to advice and resources that may be able to help you live more independently.

At the end of the form, you can make a referral to the adult care team for a formal assessment.

If the assessment shows you're eligible for our support, we'll work with you to develop your support plan.

How long the form will take to complete

The form should take around 15 to 20 minutes to complete. Make sure you have enough time to complete the form in one go, as the form cannot be saved and returned to later.

What this form is not for

This form is not for:

• emergency situations: call 999 if you, or an adult you're referring, needs urgent medical attention
• professional: if you're a professional who needs to refer an individual to adult care, use the adults care referral for professionals form
• equipment and adaptations requests: if you want to refer yourself or another adult to occupational therapy, fill in an occupational therapy referral, an occupational therapy assessment can help identify what you can do and what equipment or adaptations will help you stay safe and independent
• reporting safeguarding concerns such as abuse and neglect: you'll need to complete a safeguarding form