Make a professional referral

For example as a care provider, GP, clinician

The web form is currently unavailable. We are working to get it back online as soon as possible.

If you have an emergency safeguarding concern that cannot wait until we get our systems back online, call our out of hours service on 0300 555 1373.

Initial details
Your details
Person in need of support
Their GP details
Referral details
Contact
Supporting documentation
Review

Data protection

The personal data you provide will be protected and handled in accordance with the General Data Protection Regulation (GDPR). For more about how we use your information, see our privacy notice.

Please note that Adults' Health & Care only manage referrals for individuals aged 18 or over. If the referral is for someone under 18, please contact Children's Services. For support in Preparation for Adulthood (transition assessment), please visit the Transition to adulthood web page.

Initial details

Contact reason What is your reason for contacting us today? Follow up on previous request Help or information on care and support

Visit Connect to Support Hampshire for useful information and advice.

Circumstances Have circumstances changed for the person who is in need of support? No Yes

If you have already contacted Adults' Health & Care regarding this matter and your circumstances have not changed, please await a response from our team. We will contact you as soon as possible. Thank you for your patience.

Visit Connect to Support Hampshire for useful information and advice.

Individual age Is the individual over 65? No Yes

Further details about your request

Please make one referral per resident. If there are multiple reasons for the contact, please refer to these in the notes on the form.

What is the main reason for your contact?

We do not issue walking aids (for example sticks or frames), wheelchairs or pressure relief (for example cushions). If your query relates to these issues, please contact the customer's GP surgery as they can facilitate these requests.

If you or someone else is in imminent danger, phone the police on 999 or call them on 101 if it is less urgent.

A safeguarding concern is where there is reasonable cause to suspect that an adult who has or may have needs for care and support and is at risk of or experiencing of abuse or neglect

Further details about your request

Please make one referral per resident. If there are multiple reasons for the contact, please refer to these in the notes on the form.

What is the main reason for your contact?

If you or someone else is in imminent danger, phone the police on 999 or call them on 101 if it is less urgent.

A safeguarding concern is where there is reasonable cause to suspect that an adult who has or may have needs for care and support and is at risk of or experiencing of abuse or neglect

Consent

If you are submitting this referral on behalf of someone else, please note that we may need to speak to the individual directly to obtain their consent before putting any services in place.

Has the individual consented to you making this request? No Yes

Please provide a reason that you have not got consent