Newark and Sherwood Homes Careline Services Referral/Enquiry

Newark and Sherwood Homes Careline Services
Referral/Enquiry
Person being referred
Name.......................................................... DOB..........................
Address....................................................... Tel:...........................
...................................................................................................
Details of referrer
Name.......................................................... Tel:..........................
Agency/Relation to
client...........................................................................................
Make appointment with?
....................................................................................................
Details of property
Tenure:
Private/rented (landlord :...................................................)
Do you have a plug in telephone socket?
Yes
No
Is there an electric socket within 2m/6ft of the telephone socket?
Yes
No
Where did you hear about the Careline?
NSH Website
Home from Homes
Leaflet
Other...................
Please tick if you are interested in any other support services:
Additional sensors:
Fall detector
Panic alarm
Smoke Alarm
Carbon Monoxide Alarm
Flood Alert
Welfare calls (7 days a week)
Welfare visits (Mon – Fri)
Additional tenancy assistance
........................................................................................................
For office use only
Action taken
Passed to..................................... By................................Date..........
Appointment.............................................................
Other action.............................................................
Fitted Yes/No (if no give reason).................................Date.................
If you would like this document in another language or format, or if
you require the services of an interpreter, please contact us.
Prosimy skontaktować się z nami, jeśli chciał(a)by Pan(i) uzyskać ten dokument w innym
języku lub formacie albo też potrzebuje Pan(i) skorzystać z usług tłumacza ustnego.
(Polish)
(Mandarin)
(Portuguese)
Audio Tape
V.8