Use his form to:

  • request support from Adult Social Care, either for yourself or someone else
  • to report abuse or neglect of an adult

Before you begin...

You will need to supply the following:

  • Your details
  • If you are making a referral on behalf of someone else you will be asked for information about them
  • Information about other people or services who are involved
  • The person’s GP Details if known

If your referral also relates to safeguarding, we will ask you to provide details of your concerns and the category of abuse.

Please include as much information as possible.

Your details will be kept strictly confidential.

This form has a 30-minute time limit per page.