RJN Care Solutions

Referral form

Refer yourself, a loved one or someone you support.

Fields marked * are required.

1. About You (Person Making the Referral)

Full Name *

Relationship to the Person *

Email Address *

Phone Number

Organisation (if applicable)

2. Person Requiring Support

Full Name *

Date of Birth

Address

Preferred Contact Method

Primary Support Need (select all that apply)

Mental health recoveryLearning disability supportDaily living supportCommunity accessISF supportOther

Other support need

3. Reason for Referral

Brief description of support needed, risks, or important information *

Current professionals involved (if any)

4. Preferred Support Type

Select all that apply

Support Worker ServiceRecovery ProgrammeBespoke Assessment & Keep-in-Touch SupportFamily-inclusive Support Planning

Preferred Days / Times & Frequency

Urgency of Referral

5. Consent

I confirm the person has agreed to this referral. *

Signature (type your full name) *

Date *

We will review your referral and contact you via email.