Health professionals adult contact referral form

All the information in the following document is confidential. Use of this form acknowledges the response time for this referral will be up to 72 hours for none hospital referrals and up to 48 hours for those requesting support to facilitate a hospital discharge.


If you have any follow-up information or issues regarding the content of a referral please contact the adult care office you submitted the form to on their GCSX email account to ensure information remains secure.

To determine an individual's social care needs we require a minimum of data. The mandatory information which will enable us to progress your request is highlighted with an asterisk. Client consent is essential to further this referral. GPs and other Health professionals are requested to consider continuing health care needs prior to completing a referral.

Once you have completed and submitted the online form you will be advised to print the completed form for your own records.

If you would prefer to save the document to your computer as a PDF, you need to select "print" from the toolbar at the top of your browser. You should then see the print options window. The next step depends on which browser you are using:

If you are using Google Chrome, please select "change printer". You should then see an option to save as PDF. Tick this option and select the save button. This will allow you to save the document to your computer.

If you are using Internet Explorer you need to select "select printer". You should then see an option titled "CutePDF Writer". Select this option and Select "print". You will then be able to save a PDF version of the form to your computer.

Complete health professionals adult contact referral form (opens in a new window)