Refer a Loved One for Care

Service User Details

Enter the service user's personal details and medical information. Fields marked with * are required.

Personal Information

Title

Surname *

First Name *

Date of Birth *

Ethnicity

Language

NHS Number

Interpreter Required?

Yes No

Digital Inclusivity

Access to Wi-Fi?

Yes No

Access to Smart Devices?

Yes No

Landline Number

Next of Kin

Name *

Relationship

Telephone *

Medical Information

Reason for Support *

What Input Would You Like From Aiding Hands

Past Medical History

Current Medication

Include names of pharmacy, check concordance; blister pack or boxed.

Social Circumstances & Environment

Provide details about the service user's living situation and environment.

Environment & Safety

Hoarding?

Refer to Clutter Image Rating Scale

Yes No

Fire Risk? (Do they need LFB referral?)

Yes No

Do they have a key safe?

Yes No

Do you have pets?

Yes No

If yes, please explain what kind of pets

Any Other Risks? (Infection, etc.)

Are there any risks or hazards that our needs to be made aware of?

Other Details

Activities of Daily Living (ADLs)

Indicate the service user's level of independence for each activity. Select one option per row.

ADL Assessment

Activity	Independent	With Assistance	Fully Dependant	N/A	Other Details / Equipment
Personal Care
Toileting
Meal Prep
Cleaning
Laundry
Shopping
Mobility – Indoors
Mobility – Outdoors
Stairs / Steps
Toilet Transfer
Bed Transfer
Bed Mobility
Bath / Shower Transfers

Finances

Employment Status

Source(s) of Income

Who Manages Finances?

Lasting Power of Attorney (LPA)?

Yes No

Benefits & Additional Information

Final step — provide any remaining details and submit the referral.

Benefits

How will Aiding Hands input benefit you?

Other Details

Any other information relevant to this referral

Referrer Details

Your Name *

Your Role / Organisation

Your Email *

Your Phone

Date of Referral *

Responsive and Reliable Care For You.

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Service User Details

Social Circumstances & Environment

Activities of Daily Living (ADLs)

Benefits & Additional Information

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