GP only adult contact referral form

All the information in the following document is confidential. Use of this form acknowledges that this is a routine referral for which the response time will be anything up to 72 hours.


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 amount of data. The information will enable us to progress your request more efficiently and provide a better outcome to your patient. Client consent is essential to further this referral. You are requested to consider continuing health care needs prior to completing this form.

Once the form is completed, please select submit. You will then be taken to a new screen which displays the words "Your form has been submitted". If this doesn't happen, please check that all the mandatory information has been completed and try again. Any missed sections will be marked in red.

You should receive an email to confirm your form has been submitted successfully. If you can't see an email, please check your junk folder.

Once the completed form has been received and opened by the relevant area office, you will receive a second email to confirm this.

Printing and saving the completed form

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 the GP only adult contact referral form (opens in a new window)