This form has a maximum of 17 pages
You have 20 minutes to complete each page. You may want to prepare your answers in advance.
It is appropriate to refer yourself to adult social care when:
- You are struggling with daily living tasks and you have not been able to make improvements by accessing community support or equipment available on the high street.
- You want to make changes to your life, and you are not able to do so by yourself or with the help of a carer / family / friends.
- Under the Care Act 2014, there is eligibility criteria for some services. Questions will be asked about what you can and cannot do to determine your eligibility.
In addition to a referral to adult social care you can find information and advice by:
- Visiting Care Place to find out about community support available in Ealing at www.careplace.org.uk.
- Purchasing recommended equipment on the high-street, from pharmacies and local specialist shops.
Please note: The care and support the council arranges and/or provides is not free. We will complete a financial assessment with you to work out how much you 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.
You will need
- next of kin details
- GP surgery name, address and telephone number
- explain your situation or recent changes
- information on any difficulty with daily activities and mobility