Online forms: Adult social care self referral form

This form has a maximum of 17 pages

You have 10 minutes to complete each page.

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
  • 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.