Make a professional mental health referral for a Care Act assessment

Make a professional mental health referral for a Care Act assessment

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 for:
- Section 117 aftercare referral
- Care Act assessment requests where clients' needs are predominantly connected to their mental health
If you want to make another professional referral, including for patients with dementia and no other mental health issue, use the general professional referral form.

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.

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
Phone number
Enter their phone number, for example 020 8547 5000Format: 00000000000.
Email address
If you know their email address, you can add it here
Date of birth

DayMonthYear
NHS number
This 10 digit number helps us process the referral.
Do they need an interpreter?
What language do they prefer to use?
Tell us about anything they use to support their communication

Other

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
What kind of support do they have?
What kind of support do they have?
Have they received care in the past from Kingston adult social care?
Does a young carer (anyone under 18) provide care for them?

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 5000Format: 00000000000.
Is this person subject to Section 117 aftercare?
Rio ID number
This is used by NHS mental health professionals

Before you begin