AGE UK HARROW

Falls Prevention Support and Home Support GP Referral Form

Tel: 020 8861 7994 /7980

Email:

Please send this referral to Fax No: 020 8861 7981

Referring Clinician
Referrer Name
Referring Practice / Date of Referral
Practice Address / Tel Number
Fax Number
Email (nhs.net)
Patient Details
Name
Address / NHS Number
DOB
Tel No (Home)
Tel No (Work)
Mobile Number
Ethnic Origin / Gender
If Interpreter required what language
Next of Kin (name and contact details)
Service Specific Information:
Please tick the service you are referring to:
The Falls Support Service- 6 session exerciseprogramme based on chair-based exercises. Offered as 1:1 sessions for elderly peoplewho have had 2 or less falls but are at risk of falling. If your patient has had 3 or more falls, please refer to the Falls prevention team at STARRS. FAX 0208869 3656
Home Support- A support plan with clients once home from hospital to address other issues such as confidence, independence and accessing other services
Each client will be assessed by the Age UK Harrow coordinator and if suitable for the project, will benefit from a 6 week volunteer led support programme. At the end of 6 weeks the coordinator will evaluate the input. This service is free of charge. Further information on these and other services can be found at:
Lives Alone Yes / No
Key Safe Yes / No Key Safe details
Access to Property
Main reason for referral
If Referring to Falls, please complete the following:
Have there been any falls within the last year? If yes, how many Yes / No
Are four or more medications being taken daily?Yes / No
Does PMH include Parkinson’s Disease or a CVA?Yes / No
Is the client Diabetic? Yes / No
Is there any evidence of balance problems?Yes / No
Is it difficult to stand from sitting without using handsYes / No
Would the client benefit from chair based exercises?Yes / No
Other information
How many times has the client been to hospital (A&E or admitted) in the past 6 months:
0 , 1 , 2-4 , 5-6 or >6
What medication does the client take?
Past Medical History/Problems
Service Exclusions
We cannot:
  • Provide personal care/housework
  • Go into a home unless someone is home
  • Administer medication
  • Respond to emergencies or lift clients
  • Handle money or undertake banking
  • Write cheques or pay bills on behalf of clients

Consent
Has the client consented to sharing information with Age UK Harrow Yes / No
If client does not have capacity, has appropriate consent been sought Yes / No
Name of consenting friend/family member (for clients without capacity):
Relationship: Friend/ Family Member/ neighbour: Telephone Number:
Signature of the referee: Date:

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Age UK Harrow Referral Form – Falls Prevention Support & Home Support