First Contact Signposting Scheme Form

Please do not use this form to contact Adult Care about safeguarding matters or to request an urgent assessment as this email inbox is not always regularly monitored. Please contact Call Derbyshire on 01629 533190 if your concern is urgent.

Please complete this form to make a referral to the First Contact Derbyshire Signposting Scheme. You can make a referral for yourself, a family member or a friend. If you're a professional you can refer a client/patient.


If you're making a referral on behalf of someone else you must get their permission first. By completing the 'statement of consent' you are confirming that you've gained their consent and explained the scheme to them.

If you have any problems making a referral to the First Contact Signposting Scheme or have any queries, please email firstcontact@derbyshire.gov.uk

All the information in the following document is confidential and will be submitted securely. If you provide your email address, you will receive an email upon successful submission followed by a second email to confirm the referral has been received and opened. 

Printing and saving the completed form

Once you've completed and submitted the online form you can print it for your own records. 

If you'd prefer to save it as a PDF, you'll need to go to the settings menu in your browser and select 'print'. You should then see the print options window. The next step depends on which browser you are using:

  • If you're using Google Chrome, select "change printer." You should then see an option to save as PDF. Tick this option and click the save button. 
  • If you're using Internet Explorer select "select printer." You should then see an option titled "CutePDF Writer". Select this option and select "print" (although you select 'print' the document will in fact give you options to save).  

Note: Asterisks (*) indicate required information.

errorPlease correct the information in the fields highlighted below.
1. Contact details





















2. Alternative contact details






3. Housing details

Please select the housing tenure that best matches your current circumstances.






4. General questions for all age groups




























5. Further details






Privacy notice

This form is designed to help you access relevant community based services. Information provided on this form will be held securely on the Derbyshire County Council Adult Care database. Under the Data Protection Act 1998 you have the right to access this information. Under the Act, information on this form will be shared with other organisations, which form part of the First Contact Partnership. The First Contact partner organisations are asked to report back to Adult Care and share basic details about the outcome of referrals they have received from First Contact. This data will only be used to create anonymised statistics and reports to help assess the success of the scheme.Your information will not be shared with anyone outside the First Contact Partnership without your prior agreement.



If you experience any problems with this form please contact contact.centre@derbyshire.gov.uk and quote form ID: ILF/561/09