Self Referral

If you’d like to find out how the HomeCareDirect service can benefit you, please give us a call on 0845 061 9000 or fill in our referral form below and we will contact you.

All information received by HomeCareDirect regarding our clients and their staff is confidential and only those people who need to know the information will have access to it, in line with data protection legislation and our policies on confidentiality, record keeping and information sharing.

Name;*
How would you like to be addressed;*
Date of Birth;
Address;*
Telephone Number;*
Email Address;
Next of Kin;
Relationship to You;
Their Address (if different from yours);
Their Telephone Number;
Social Worker/Care Manager/Other Professional contact details;
Do you have an advocate who helps you? If so please provide details below
Your current circumstances and support/service you would like from HCD;
Aims/outcomes of support/service you’d like from HCD;
Medical information/history;
Do you require documents and correspondence in a different format (easy read, braille, different language)? If so please let us know and we will arrange this for you
What hours of support would you like each week and when would you like these (e.g. 28 hours a week, 4 hours a day from 11am to 3pm, 7 days a week);
Do you already have funding available for you care at home? If so how much? And from whom? (e.g. local council, direct payment, NHS);
If you do already have funding available what is your NHS or Care First number;
If not would you like HCD to support you with gaining a personal budget to fund your care at home?
Are there any historical or existing Safeguarding issues?*
- Yes
- No
If yes please give details;
Any other useful information;
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- Yes
- No
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