Make a professional referral to Kingston adult social care

Make a professional referral to Kingston adult social care

Professionals are anyone who works with members of the public. This includes social workers, doctors, nurses, housing officers, police officers or any other role that works with vulnerable adults.
Use this form if you're working with someone and you want to refer them for:
- Care Act assessment
- Occupational Therapy assessment
- Decision Support Tool (DST) - for NHS continuing healthcare administrators only
Mental health referral

Use the mental health Care Act assessment form instead if:
- their support needs are predominantly because of their mental health
- they need section 117 aftercare
Use the general Care Act referral form if the person has dementia but no other mental health need.

Make a mental health Care Act referral

Safeguarding

Do not use this form if someone is in immediate danger - dial 999.

If someone is being abused or neglected, make a safeguarding concern referral
Before you begin
This form has 6 pages and will take around 10 minutes to complete.

Try to speak to the person to make sure they want help from us. We may not be able to help someone who does not want it.
Privacy notice
Read our privacy notice and data protection policy for information about how we process your data.
Check the box if you are happy to proceed*

I have read and accept the privacy notice

Type of referral
What kind of referral do you want to make?*

Care needs assessmentOccupational therapy (OT) assessmentBoth care needs and OT assessmentDecision Support Tool (DST) - for NHS continuing healthcare administrators onlyI don't know

What Occupational Therapy cannot help with
We want to make sure that people are referred to the correct service for their needs.

Our OT team does not provide and cannot help with:
- physiotherapy
- walking aids, wheelchairs or mobility scooters
- pressure care (like mattresses or cushions)
- hand therapy
If you know that your patient needs help with one of these, you'll need to refer them to their GP to access these services through the NHS.
Are you making a referral for physiotherapy?*

YesNo
Are you making a referral for walking aids, wheelchairs or mobility scooters?*

YesNo
Are you making a referral for pressure care? (Like a mattress or cushions)*

YesNo
Are you making a referral for hand therapy?*

YesNo
Confirm that you understand we cannot provide these services*

I understand Kingston Council's Occupational Therapy team cannot provide these services

Patient or client details

Tell us the details of the person you want to refer to us.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

Town or CityCounty

Postcode
Address where the person lived before they moved into a care home (if relevant)

Street Address

Street Address Line 2

Town or CityCounty

Postcode
Phone number*
Enter their phone number, for example 020 8547 5000
Email address
If you know their email address, you can add it here
Date of birth*

DayMonthYear
NHS number
Including this number helps us identify the correct person
Do they need an interpreter?*

YesNoI don't know
What language do they prefer to use? *
Tell us about anything they use to support their communication

Hearing aid or cochlear implantBritish sign language interpreterBrailleLarge print documentsOther

Support they already get

Tell us about any support they're already receiving.
Do they have any support right now? This includes both informal support (like care from family) or formal support from another organisation*

YesNoI don't know
What kind of support do they have? *
Have they received care in the past from Kingston adult social care?*

YesNoI don't know
Does a young carer (anyone under 18) provide care for them?*

YesNoI don't know

GP details

Tell us about this person's GP surgery
Surgery name
Address

Street Address

Street Address Line 2

Town or CityCounty

Postcode
Phone number
Enter their GP's phone number, for example 020 8547 5000
Their previous GP

If the patient's GP surgery changed when they were placed, tell us the details of the GP they had before.
Previous GP surgery (if known)
Previous GP surgery address (if known)

Street Address

Street Address Line 2

Town or CityCounty

Postcode
Previous GP surgery phone number (if known)
Enter their GP's phone number, for example 020 8547 5000

Before you begin