Age UK Milton Keynes > Safe at Home 3rd party referral

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Safe at Home third party referral

Thank you for making this referral on behalf of another person. Please complete the form below ticking all boxes that apply.

We shall need full details for the person you are referring to us as well as your own contact details for follow up if necessary.

* compulsory field

Security: -

Would they like Police advice on Security?
Would they like information on neighbourhood watch?
Would they like advice on bogus callers?
Would they like advice on how to reduce junk mail?

Fire safety: -

Does the property have working smoke alarms on every floor?
Does anyone in the property have reduced mobility?
Would they like a fire risk check and free alarms fitted?

Health & Social care: -

Would you like Adult Social Care to make contact ?
Has the person fallen recently (indoors)?
Has the person fallen recently (outside)?
Would they like advice from our Falls Liaison Officer?
Does he/she have difficulty managing everyday tasks?
Does he/she have difficulty getting in or out of their property?

Home safety: -

Would they like to be connected to the Community alarm/Telecare?
Would they like Advice on insulation/heating?
Do they have any Home repair issues?

If so please give details

The person's title*

Their first name*

Their surname*

House name/number*

Street name*

Town*

Post code

Their telephone*

Date of birth DD/MM/YYYY if known

Your full name*

Your email address*

Telephone*

Your relationship to house occupant*

Interpreter required*

With whom should we make initial contact*

Approval to pass on these details.*

yes, please pass them to other agencies to action
No

Data Protection:	All information provided through this form will be used solely for the purpose of this enquiry and no details will be passed to any third party who is not part of the Safe at Home service.

We may need to pass on these details to enable other agencies to action your referral. If you are not happy with this or feel that you don't have the authority, please click on the 'No' button above.

Safe at Home is a multi-agency initiative joining together Milton Keynes Community Safety Partnership, Thames Valley Police, Bucks Fire & Rescue Service, the NHS and the Primary Care Trust.

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Safe at Home third party referral