Discharge Referral Form

Ward Name: *

Discharge Date: *

Client Details

Title -- Select an option -- Mr Mrs Miss Ms Dr Sir

First Name *

Surname *

DOB *

Telephone Number *

Full Address *

Circumstances we need to be aware of

Has depression and/or anxiety Has a hearing problem Has a visual impairment Is housebound/has poor mobility Has cognitive impairment Lives on their own Other None

If other, please describe *

Services required from Age UK Plymouth

Basic meal preparation Hygienic cleaning of kitchen and bathroom areas Laundry and bed changing Local shopping carried out on their behalf or via an assisted trip (shopping is cash only) Paying bills and managing appointments Support to visit friends Reading and helping with correspondence Setting up online or telephone shopping as required Support in engaging with community groups or activities or local trips out Vacuuming Befriending and companionship visits in the comfort of their own home Support in attending health appointments Collecting prescriptions Benefits advice

Patients Hospital number *

GP Details

GP Surgery *

Address *

Telephone Number *

Please state reason for Hospital admission *

Are there any known lone worker risks?

Yes No

If yes, please describe: *

Referrer Details

Name *

Job Title *

IHDT DTA ECTT/ CCRT/ UCR Plym Neuro

Telephone Number (inc Ext. Number) *

Email Address *

Declaration

Do you have the client's consent for this referral?

Yes No

I understand that any information given will be treated in the strictest confidence and in accordance with the Data Protection Act 2018.

Please tick

Referrer Signature/Name *

Date *

Submit