Professional Referrals PROFESSIONAL REFERRAL (QMS-F036A) Contact Secure Referral Gateway: Please complete the form below for rapid response triage. For urgent same-day discharges, please call our Care Manager on 020 3951 4660Service User Full NameService User ID NumberOperating Local Authority- Select -HaringeyIslingtonWaltham ForestBarnetOtherCare Funding & Financial Arrangements- Select -Local Authority Managed (Direct Commissioning)NHS Funded (Continuing Healthcare - CHC)Direct Payments (Personal Budgets)Self-Funded (Full Cost)OtherReferrer NameJob Role / Title- Select -Hospital Discharge CoordinatorDistrict Nurse / Community MatronGP / DoctorOccupational Therapist (OT)Brokerage / Commissioning TeamContinuing Healthcare (CHC) NurseOtherSecure Work EmailWork Contact Number Referring Organisation / Hospital- Select -Barnet HospitalRoyal Free HospitalNorth Middlesex University HospitalWhittington HospitalChase Farm HospitalWhipps Cross University HospitalSt Ann's Hospital (Haringey)Edgware Community HospitalLondon Borough of Barnet (Social Services)London Borough of Haringey (Social Services)London Borough of IslingtonLondon Borough of Waltham ForestIntegrated Care Board (ICB) – NCLGP PracticeOtherRisk AssessmentFall RiskMoving & Handling / Hoist RequiredSkin Integrity (Pressure Care)Medication Management / InsulinCognitive Impairment / DementiaChoking Risk / Swallowing DifficultiesChallenging Behaviour / AggressionHoarding / Environmental RiskCatheter / Stoma CareKey Safe Access RequiredNone KnownTarget Start DateImmediate (24-48 Hours – Rapid Response)Urgent (This Week)Planned Discharge (Future Date)OtherDate of AssessmentReason for Referral & Care NeedsPlease summarize the service user’s current situation, primary diagnosis, and the support required (e.g., 4 calls a day, double-up). Do not provide names of the service userReferral Documentation- Select -I will email the Discharge Summary / Care Plan separately.OtherSend Secure Referral
