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Safe and Connected referral form
Safe and Connected referral form
Is the enquiry for yourself?
*
Yes
No
Personal details
Name
Address
Postcode
Phone number
Email address
Who is it for?
Name
Address
Postcode
Phone number
Email address
Who are you?
What is your relationship to the above person?
Family relative
Friend/neighbour
Social care professional
Health professional
Other
Name
Address
Postcode
Email address
Phone number
Does the service user (person you are making the enquiry for) have Mental Capacity?
Yes
No
Don't know
Reason(s)
Please tick all that apply as reason(s) for your enquiry
To support day-to-day living and remain independent (Enablement)
Have had a recent fall or falls
Feel vulnerable
Discharged from hospital
Other
Please include any additional information you would like us to know
Interested in which service?
What service were you interested in? (Tick any that apply)
Safe Alert (£5.35 per week)
Safe Response (£7.55 per week)
Safe & In Touch (£10.00 per week)
Is there a home landline at the property?
Yes
No
Don't know
Are there call restrictions such as barring, blocked call?
Yes
No
Don't know
Is there a power socket within 6 feet of the main landline on the same side of the wall?
Yes
No
Don't know
Does the person you are making the enquiry for have any existing Telecare equipment?
Yes
No
Don't know
Has anyone in the household tested positive for Covid 19, or shown symptoms in the last two weeks?
Yes
No
Don't know
The service user (person you are making the enquiry for) will be contacted to discuss the referral via telephone within 5 working days, if this is not appropriate, please advise why and who should be contacted
How did you hear about our service?
Terms and conditions
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Privacy policy
Terms of use
By submitting this form you agree to our privacy policy and terms of use.
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