ONLINE REFERRAL

Make a Referral

Thank you for considering Pillarays Living Care. Please complete the referral form below and our team will review your submission as soon as possible.

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Need Help?

Email: referrals@pillarays.co.uk

Tel: +44 016 0436 0922

Personal Details of the Individual Being Referred

Full Name *

Date of Birth

Gender

NHS Number

Current Address

Telephone Number

Email Address

Referral Details

Relationship to Individual *

Referrer's Name *

Organisation (if applicable)

Referrer's Email

Referrer's Phone Number

Support Needs

Primary Support Needs (Select all that apply)

Learning Disability Autism Mental Health Physical Disability Challenging Behaviour Dual Diagnosis Other

Other Support Need

Brief Description of Needs & Support Required

Current Living Arrangement

Urgent Need / Risk of Homelessness?

Health & Risk Information

Medical Conditions (if any)

Current Medication (if known)

Are there any risk concerns? (Self-harm, aggression, substance use, etc.)

If Yes, please provide details

Are there any safeguarding concerns?

Safeguarding Details

Funding & Placement

Has funding been approved or applied for?

Funding Source

Preferred Placement Location

Ideal Move-in Date

Supporting Documents

Upload any relevant documents to support this referral.

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Consent & Declaration

Digital Signature / Typed Name *

Date

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