Secure Referral Form

Referrer Information

Full Name *

Professional Role *

Organisation *

Email Address *

Phone Number *

Service User Information

Full Name *

Date of Birth *

NHS Number (Optional)

Current Setting *

Primary Diagnosis & Conditions *

0/500 characters

Clinical & Care Information

Risks & Behaviours *

0/500 characters

Communication Needs *

0/500 characters

Funding & Timeline

Funding Route *

Target Admission Date

Additional Information

Documents Upload

Please email documents separately to:

info@complexneeds.com

Include: Care plan, MAR charts, risk assessments, medical reports

Additional Notes

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Consent & Legal Basis

I confirm that I have the lawful basis and/or consent to share these details for the purpose of care assessment. I understand that this information will be processed in accordance with GDPR and data protection regulations, and will only be used for assessing suitability for care at Kings Lodge.

Your referral will be reviewed within 24 hours. For urgent referrals, please call +44(0)1737 822221

Data Protection & Privacy

Referrer Information

Service User Information

Clinical & Care Information

Funding & Timeline

Additional Information

Consent & Legal Basis