Enfield Health and Adult Social Care - Amazon Web Services



Enfield Health and Adult Social Care

Access Service and Independent Living Resource Centre

Standard Referral Form

Only Use this form for Adult Social Care Services (age 18+).

Mental Health services in Enfield are delivered through the Barnet, Enfield and Haringey Mental Health Trust by contacting the Intake team via their website at:

All fields are mandatory

|Client Details |

|Forename: | |Surname: | |

|Title: | |Date of birth: | |NHS number: | |

|Address: | |

|Postcode: | |Social Care ID (if known): | |

|Telephone | |Mobile: | |

|Tenure |Owner occupied ( |Housing association ( |Other (please state): |

|(if known): |Private rented ( |Sheltered accommodation ( | |

| |Council ( |Residential/nursing home ( | |

|GP: | |Practice Name and Telephone Number: | |

|Name of Next of Kin or most appropriate contact: |

|Telephone: | |Mobile: | |

|Address: | |

|Reason for Referral |

|Health ( Neglect ( |

|Personal Care ( Social Isolation ( |

|Mobility issues ( Falls ( |

|Main carer unable to continue in their caring role ( |

|Support with daily living tasks (please list): ( |

| |

| |

|Other – please describe: |

| |

| |

|Communication needs |

|Hearing Impairment ( Interpreter required ( |

|Other, please state: |

|Safeguarding issues |

|Yes ( No ( If yes, please describe: |

| |

|Other Issues |

| |

|Medical Information | |

|(e.g. Arthritis – hips and knees | |

|affected, diabetes, COPD, etc) | |

|Medication | |

|List current medication | |

|Identified Need / Current |(Please note: Issues requiring mobility aids – walking sticks, frames, trolleys – should be referred via GP to the |

|Difficulty |Physiotherapy department for a mobility assessment) |

|(please describe e.g. difficulty | |

|accessing the bath, stair mobility,| |

|personal care tasks) | |

| | |

| |Functional Ability (Please enter on scale 1 – 5 – see right) |

| | |

|Please enter on scale 1 – 5 |Chair / settee ↓ |

|1 = Independent, no difficulty |Bed ↓ |

|2 = Independent with equipment |Toilet ↓ |

|3 = Independent with difficulty |Stairs ↓ |

|4 = Dependent on assistance | |

|5 = Unable to carry out | |

| | |

| | |

| | |

| | |

| |Mobility ↓ |

| |Bath / Shower ↓ |

| |Personal Care ↓ |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

|Any further relevant information? | |

|(Attends a day centre on Mondays) | |

| | |

|Referrer Details |

|Name: | |

|Address: | |

|Postcode: | |

|Telephone: | |

Is service user / patient aware of referral? Yes ( No ( If yes, do they consent to the sharing of information with other health/social care organisations? Yes ( No (

Signed:

Date:

Please submit this form to the Access Service by:

Email: adultsocialcare@.uk

Fax: 020 8379 2810

Post: Access Service, HASC, Civic Centre, Silver Street, Enfield, EN1 3XA

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