AGE UK HARROW

Winter Pressure

Tel: 020 8861 7994 / 07438 025 779

Email:

Please send this referral to Fax No: 020 8861 7981

Referring Clinician
Referrer Name
Referring Practice / Date of Referral
Practice Address / Tel Number
Fax Number
Email (nhs.net)
Patient Details
Name
Address / NHS Number
DOB
Tel No (Home)
Tel No (Work)
Mobile Number
GP Name & Address
Ethnic Origin / Gender
If Interpreter required what language
Next of Kin (name and contact details)
(mobile number)
Service Specific Information:
Please tick the service you are referring to: (only tick ONE box)
The Falls Support Service – This programme includes chair-based exercises. We offer 1:1 sessions for elderly people
Home Support- A support plan with clients once home from hospital to address.
Each client will be assessed by the Age UK Harrow and Age UK Brent coordinator and if suitable for the project, will benefit from a 6 week volunteer led support programme. At the end of 6 weeks the coordinator will evaluate the input. This service is free of charge. Further information on these and other services can be found at: www.ageukharrow.org.uk
Please tick
Lives Alone Yes / No
Key Safe Yes / No Key Safe details
Access to Property
Main reason for referral
If Referring to Falls, please complete the following:
Have there been any falls within the last year? If yes, how many Yes / No
Are four or more medications being taken daily? Yes / No
Does PMH include Parkinson’s Disease or a CVA? Yes / No
Is the client Diabetic? Yes / No
Is there any evidence of balance problems? Yes / No
Is it difficult to stand from sitting without using hands Yes / No
Would the client benefit from chair based exercises? Yes / No
Service Exclusions
We cannot:
·  Provide personal care/housework
·  Go into a home unless someone is home
·  Administer medication
·  Respond to emergencies or lift clients
·  Handle money or undertake banking
·  Write cheques or pay bills on behalf of clients
Consent
Has the client consented to sharing information with Age UK Harrow and Age UK Brent Yes / No
If client does not have capacity, has appropriate consent been sought Yes / No
Name of consenting friend/family member (for clients without capacity):
Relationship: Friend/ Family Member/ neighbour
Telephone Number:
Mobile Number
Email Address :
Signature of the referee: Date:

Please make sure that the whole form is filled out, try not to leave any blank spaces. If you need help in filling out the form or are unsure about some questions call 020 8861 7994 / 07438 025 779/ 0208 861 7985

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Age UK Harrow Referral Form