Make a Referral

Step 1 of 5

Who Is Making This Referral?

Please select the option that best describes you. The form will adapt to show the relevant fields for your situation.

Professional / Local Authority

For social workers, care managers, NHS staff, GPs, hospital discharge teams and local authority commissioners referring a client.

Individual / Family

For individuals enquiring about care for themselves, or family members and friends enquiring on behalf of a loved one.

Step 2 of 5 — Professional Referral

Your Details

Please provide your contact details and organisation information. Fields marked * are required.

Referrer Information

Full Name * Please enter your full name

Job Title * Please enter your job title

Organisation Name * Please enter your organisation name

Organisation Type * Please select your organisation type

Email Address * Please enter a valid email address

Phone Number * Please enter your phone number

Are you the main point of contact for this referral? * Please make a selection

Secondary Contact Details

Name

Email

Phone

Step 2 of 5 — Individual / Family

About You

Tell us a little about who you are and how we can best reach you.

About the Enquiry

I am enquiring… *

For myself On behalf of someone else

Your Full Name *

Your Relationship to the Person *

Email Address * Please enter a valid email address

Phone Number * Please enter your phone number

Preferred Contact Method

Best Time to Call

How did you hear about us?

Step 3 of 5

About the Person Needing Care

Please provide details about the individual you are referring. All information is held securely and confidentially.

Personal Details

First Name * Please enter the client's first name

Last Name * Please enter the client's last name

Date of Birth * Please enter the client's date of birth

Gender

Phone Number

Current Address

Address Line 1 * Please enter the client's address

Address Line 2

Town / City * Please enter the town or city

Postcode * Please enter the postcode

Next of Kin / Emergency Contact

Name

Relationship

Phone Number

Step 4 of 5

Care Needs & Requirements

Help us understand the level and type of support needed so we can prepare the most appropriate response to this referral.

You don't need to have all the answers at this stage. Provide as much information as you have — our team will follow up to gather any additional details needed.

Service & Reason

Service Required * Please select the service required

Urgency * Please select the urgency level

Primary Reason for Referral * Please describe the reason for the referral

Preferred Start Date

Is care currently in place? * Please make a selection

Please describe the existing care in place

Health & Support Details

Relevant Medical Conditions / Diagnoses

Mental Capacity

Existing care plan or assessment available?

Mobility / Moving & Handling Requirements

Communication Needs

Behavioural or Risk Considerations

Step 5 of 5

Consent & Declaration

Before submitting, please confirm the following consent declarations. These are required to process the referral.

Consent Declarations

I have read and agree to the Privacy Policy. I understand that the personal information submitted will be used to process this referral and stored securely in accordance with GDPR. *

I confirm that to the best of my knowledge the information provided in this referral is accurate and complete. I understand that Cam Gray Support Services will use this information to assess the referral and may contact me to discuss it further. *

On submission, you will receive a confirmation email with a unique reference number. We aim to respond to all referrals within 1 working day. For emergencies, please call us directly as well as submitting this form.