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Adults Social Care Referral Form
Surrey County Council


Following receipt of this referral Surrey County Council will gather further information to be able to assess whether the person referred has an eligible need. Our policy in Surrey is to provide support for people who are assessed as having needs within Critical and Substantial risk bands. An explanation of these can be found on the Surrey County Council website under "How to access adult social care services".

Once it has been assessed that someone has an eligible need we will discuss with them the most appropriate way of meeting that need and whether or not it is necessary for the county council to provide services to meet that need.

If their needs fall outside what we can offer, we will assist them with advice, information and other support so they can find another agency or service that can help. Many people find that the assessment process is helpful in finding solutions because it provides an opportunity for individuals and/or their carers to reflect on their situation with an experienced independent person.

This form is to refer individuals and carers for Adult Social Care Assessment. The term Carer is used for someone who looks after a family member, a partner or a friend and the care they provide is unpaid. Carers under the age of 18 years of age are known as "young carers".


Person's details (for the person being referred)

Can the person be contacted via telephone? 

This should only contain numbers and be in the format
123 456 7890
Does the person live alone? 
Has the person given consent for contact to Adult Social Care? * 

Next of kin details (if known)


Carer's details (if known)


Referrer's details (if you have already provided your details above, please do not complete this section)

Does the Referrer wish their identity to remain confidential?*

Presenting Issues (for person being referred)

Please complete the relevant sections below

This will include Family, Friends, Voluntary Services, Schools, Colleges and other non Social Care organisations, any other professionals or Housing Related Support (formerly Supporting People Services) from the housing provider. Please provide details.
: Is support/prompting required with preparing food and drinks, eating and drinking, housework, shopping and laundry? Please provide details.
: Is support/prompting required around looking after, washing, dressing, going to the toilet and hygiene, medication etc? Please provide details.
: Are there any difficulties moving around inside and outside the home including transfers? Are any aids currently used or required? Is there a history or risk of falls? Please provide details.
: Are there any concerns about safety, wellbeing or self neglect? Is support required to remain safe due to physical/mental health condition or behaviour that may put the person or others at risk? Please provide details.
: Is support required to access leisure, work or learning? Please provide details.
: Please add any relevant information not captured in the previous Presenting Issues. Please provide details.

Carer's section

: Is the carer at risk of breakdown? Does the carer's role impact on the carer's health? Is the carer aware of their ability to choose the level of support they may provide? Please provide details.
: Is the caring role placing the carer's employment or choice to work at risk? Does the caring role impact on the carer's ability/choice for training or learning? Please provide details.
: Is the carer able to maintain their domestic routines? Is the carer able to maintain relationships with family or friends (including parenting)? Does the carer feel isolated? Is the caring role impacting on leisure/social activities or interests? Please provide details.

Additional information for person/carer

: Is the person and/or the carer(s) currently at risk of actual or potential harm or abuse and are there any factors that increase this risk? Please provide details.
: Please add any medical conditions relevant to the person and/or the carer(s)

If Surrey County Council is going to arrange any services for an individual, there may be a need for them to pay a contribution. If the service is likely to be chargeable, advice/help is available. A member of staff, will give the individual (or their representative) a call (within the next few days) to explain this further and answer any questions.

Surrey County Council does not charge for

  • Services provided to Carers
  • Equipment
  • Information and advice
  • Assessments and Professional Support
  • Reablement up to 6 weeks

All other services are chargeable.