Referral Form

Rushcliffe HLHFF

Please complete IN FULL and return to the SMaRT Messenger Team using the contact details overleaf.

Client details
Name
Preferred name for messages
Address
Postcode
Phone number(s)
Date of birth
National Insurance number
Normal living status / ☐Alone☐With partner
☐With family☐With others
Connectivity at home / ☐Existing Internet connection
☐BT landline☐Other provider landline
Referrer details
Date of referral
Name of referrer
Referring organisation
Main phone number
Mobile number
Email address
Next of kin / primary carer details
Name
Address
Postcode
Phone number(s)
Email address
Relationship to client
Messaging requirements - please tick all that apply
☐Wellbeing checks / ☐Carer reminders
☐Medication reminders / ☐Health and safety checks
☐Appointment reminders / ☐Local events
☐Other (please state)
What objective does this referral meet?Please tick all that apply
☐Reduces need for residential care / ☐Reduces burden on carers
☐Unlocks resources / ☐Contributes to LTC support
☐Increases choice and independence / ☐Reduces acute hospital admission
☐Supports hospital discharge / ☐Reduces accidents and falls
Intended outcome - please tick all that apply
☐Prevent admission to residential care / ☐Reduce stay in residential care
☐Prevent admission to nursing care / ☐Reduce stay in nursing home
☐Prevent admission to hospital / ☐Reduce stay in hospital
☐Prevent need for additional medical care / ☐Prevent breakdown of family care
☐Prevent need for additional personal care
(please specify reduction in hours) / ☐Other (please specify)

Please return to the SMaRT Messenger Team by:

Email:

Secure emails from nhs.net can be received at this address

Phone:0115 844 3016

Post:SMaRT Messenger, Corporate Services
Nottingham Community Housing Association
12-14 Pelham Road, Sherwood Rise
Nottingham, NG5 1AP

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