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Refer someone for an assessment of care and support

Adult Social Care Referral Form - Guidance

Please ensure that all sections of the form are completed before submitting to help us provide an effective response.

There is an option to save the form and return to it again before submitting if you do not have all of the necessary information to hand. There is also an option to print the form once it has been submitted.

The Initial Assessment Team will assess all referrals on receipt. Please provide as much information as possible in order to help us prioritise referrals.

We may contact you to request further information if required.

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* indicates required field

Address Picker

Enter postcode or street name

Referrer

Referred by *

Referrer relationship *

Referrer's Title

Referrer's Forename *

Referrer's Surname *

Referrer's Address * Select a Wigan Address

Postcode *

Main Telephone Number *

Other Numbers

Referrer's Email Address *

Confirm Referrer's Email Address *

Availability

I will be available please contact meI will not be available please contact...

Contact Title

Contact Forename *

Contact Surname *

Telephone Number *

Please provide as much contact information as possible: including availability times and dates, pager numbers, mobile numbers, and email addresses where possible.

0 of 630 characters

Adult's name and address

Surname *

Forename(s) *

Gender *
MaleFemale

Date of birth *

Address * Select a Wigan Address

Postcode *

Telephone Number *

Responsible local authority *

Current address (if different from above) Select a Wigan Address

Postcode

GP Practice

NHS Number

Have they been formally diagnosed with any medical conditions? 0 of 300 characters

Is the person aware of the contact *
YesNo

Please give details of why they are unaware of this contact *

0 of 500 characters

Adults' ethnicity, nationality, religion and communication needs

Ethnicity *

White

Mixed

Asian or Asian British

Black or African or Caribbean or Black British

Other ethnic group

Any other ethnic group

Nationality *

Religion *

Any other religion

Communication

First language *

Does the person need an interpreter/signer? *
YesNo

Reasons for referral/request for Adult's social care services

Please use the following headings to structure your referral and identify how a referral to Adults's social care will address the issues you have highlighted and lead to an improvement in the situation.

1. Has there been a recent decline in their ability? If yes, please describe. *

0 of 1625 characters

2. Are they struggling at home with daily tasks? If yes, please describe. *

0 of 1625 characters

3. Have they been falling? If yes, please describe. *

0 of 1625 characters

4. Have they had trouble remembering things? If yes, please describe. *

0 of 1625 characters

Please state the specific outcomes you are looking for and provide any further information to support this referral. *

0 of 1625 characters

Other household members (including non-family members)

Add a household member

Enter household member (including non-family member)

Surname *

Forename *

Relationship to Adult *

Is this person the Principal Carer? *
YesNo

Date of birth *

Date of birth not known

Is also being referred? *
YesNo

Significant others who are not members of the household

Add a significant other

Enter significant other who is not a member of the household

Surname *

Forename *

Relationship to Adult *

Is this person the Principal Carer? *
YesNo

Address * (if unknown please enter 'Unknown') Select a Wigan Address

Postcode * (if unknown please enter 'Unknown')

DOB

Telephone number

Key Agencies

Add a key agency

Enter Key Agency

Agency Type *

Agency name/office/... *

Contact Title

Contact Surname *

Contact Forename *

Address * Select a Wigan Address

Postcode *

Telephone number *

Declaration

The following MUST be completed before the referral is submitted.

Has the adult given consent for the information to be shared? *
YesNo

Give reason(s) why consent was refused *

0 of 500 characters

*Please note: the information provided on this form cannot be modified once submitted. There will be an opportunity to print the form once it has been submitted.

I declare that the information I have provided is true and accurate to the best of my knowledge.

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Refer someone for an assessment of care and support

Adult Social Care Referral Form - Guidance

Save Form Progress

Address Picker

Referrer

Availability

Adult's name and address

Adults' ethnicity, nationality, religion and communication needs

Ethnicity *

White

Mixed

Asian or Asian British

Black or African or Caribbean or Black British

Other ethnic group

Religion *

Communication

Reasons for referral/request for Adult's social care services

Other household members (including non-family members)

Enter household member (including non-family member)

Significant others who are not members of the household

Enter significant other who is not a member of the household

Key Agencies

Enter Key Agency

Declaration