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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