Initial Care Enquiry Form

Use this form for an adult aged 18 to 65 inclusive. Our core areas are Westminster, Hammersmith & Fulham and Barnet, with other areas considered case by case. Our team will contact you within one day.

Referrer's Name *

Referrer’s Email Address

Referrer’s Contact Number

Name of the person needing support

Borough

Westminster
Hammersmith and Fulham
Barnet
Other

Urgency

Routine
Urgent
Hospital discharge

Tell us about the situation / provide a brief outline of reason for referral

Does the person consent to us contacting them?

Yes
No
Best-interests decision

Anything Else You Would Like Us to Know?

The information on this form is used to assess and process the referral. It is stored securely, accessed only by authorised members of the Inclusive Care Options team and handled in line with our Privacy Policy and UK GDPR. Information is retained only for as long as necessary in accordance with our privacy, legal and safeguarding obligations.

Initial Care Enquiry Form

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