Client Referral Form | Lamora Healthcare

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For emergencies call
0333 004 0177

All referrals are acknowledged within one working day. For urgent placements (48–72 hour mobilisation) please call us directly on 0333 004 0177 as well as completing this form. All data is processed in accordance with UK GDPR and our Privacy Policy.

Section 1 — Referring Professional

Your Full Name *

Your Job Title *

Organisation *

Your Email Address *

Your Direct Telephone *

Date of Referral *

Section 2 — Client Details

Client First Name *

Client Surname *

Date of Birth *

NHS Number (if known)

Client Address *

Client / Family Contact Number

Next of Kin — Name & Relationship

Next of Kin Contact Number

Section 3 — Service Required

Type of Service Required *

Urgency of Referral *

Proposed Funding Source *

If Local Authority Funded — Which Authority?

Approximate Hours of Support Required

Section 4 — Care Needs & Risk

Summary of Care & Support Needs *

Known Risks or Behaviours of Concern

Active Safeguarding Plans or Alerts

Safeguarding Details (if applicable)

Current Care Arrangements

MDT / Professional Involvement

Any Other Relevant Information

Declaration

I confirm I have the authority to make this referral and that the information provided is accurate to the best of my knowledge. I consent to Lamora Healthcare Ltd processing this personal data for the purpose of assessing and arranging care, in accordance with UK GDPR and their Privacy Policy.

✓ Referral Received

Your referral has been sent to referrals@lamorahealthcare.co.uk. We will acknowledge receipt within one working day and contact you to discuss next steps. For urgent placements please also call 0333 004 0177.