Council House, Priory Road, Dudley, West Midlands, DY1 1HF
www.dudley.gov.uk /

Dudley Telecare Service Referral

Dudley Telecare is a fully integrated alarm service, offering a whole range of supportive living solutions. Our aim is to enable people to continue living safely, securely and most importantly independently.
The service is available to anyone who is vulnerable and is likely to need a little extra support or assistance within the home. There is no age barrier to the service: anyone who is isolated, lives alone, feels insecure or could benefit from the service.
The Telecare solutions can be installed into any home within the community. All that is needed is a telephone line and a plug socket within two metres of this.
Referrals for the service can be made by people themselves, their relatives or advocates, staff from health, social care, housing or voluntary agencies.
If your request is urgent you will be contacted within 24 hours. Non urgent requests will be answered within 7 days.

Data Protection Statement

Your information will be processed in accordance with Data Protection legal requirements. Please see the Council's Privacy Statement and Charter

Client details

Title
First name
Last name
Date of birth (dd/mm/yyyy)
Contact tel number
Address & postcode
What type of property is the address above? * / ☐ Council Property
☐ Private Property
☐ Housing Association
Is the client aware of the referral? * / ☐ Yes
☐ No
Has a keysafe been fitted?* / ☐ Yes
☐ No
Keysafe number

Contact & Doctor's details

Next of kin/Nominated contact details

Title
First name
Last name
Contact tel number
Address & postcode

Doctor's details

Please give details of your doctor: name, hospital or surgery name, and hospital or surgery address.

Surgery/Hospital name
Doctors Name *
Surgery/Hospital address

Client circumstances

Reason for contact/summary of contact *

Medical details *

Does the client have any impairments?

Speech impairment* / ☐ Yes
☐ No
Visual impairment* / ☐ Yes
☐ No
Hearing impairment* / ☐ Yes
☐ No

Outcome sought by referrer *

Referrer details

Please supply the referrer's details if they are different to next of kin/contact details already supplied.

Title
First name
Last name
Contact tel number
Date of Referral

General enquiries: 0300 555 2345 Twitter/YouTube: dudleymbc Facebook: DudleyBorough