Online forms: Adult social care referral form

This form has a maximum of 16 pages

This is a referral form, to be used by representatives referring a resident of Ealing.

You have 10 minutes to complete each page.

It is appropriate to make a referral to adult social care when:

  • An individual is struggling with daily living tasks and has not been able to make improvements by accessing community support or equipment available on the high street.
  • An individual wants to make changes to their life and is not able to do so by themselves or with the help of a carer/family/friends.

Under the Care Act 2014, there is an eligibility criteria for some services. Questions will be asked about what the referred person can and cannot do to determine their eligibility.

In addition to a referral to adult social care you can provide information and advice by:

  • Visiting (Care Place) to find out about community support and other services available in Ealing
  • Recommending equipment which can be purchased cheaply on the high-street, from pharmacies and local specialist shops (where qualified to do so).

Please note: The care and support the council arranges and/or provides is not free. We will complete a financial assessment with the individual to work out how much he/she can afford to pay. The council may contribute towards the cost.


If the matter is urgent or you are raising a safeguarding alert, please call social services on 020 8825 8000 (adults’ option) to discuss the referral.

If there is a medical emergency, immediate danger to life, risk of injury or if a crime is being committed, dial 999.