Client Referral Form

Submit a secure online referral for an individual requiring care. For urgent referrals please call 0333 004 0177 directly.

Fields marked * are required. All submissions are processed securely and in accordance with our Privacy Policy.

Referring Professional

Your Full Name *

Job Title *

Organisation *

Email Address *

Telephone *

Date of Referral *

Client Details

Client First Name *

Client Last Name *

Date of Birth *

NHS Number (if known)

Client Address *

Client / Family Contact

Next of Kin / Name & Relationship

Service Required

Type of Service *

Urgency *

Proposed Funding *

Summary of Care Needs *

Known Risks or Safeguarding Concerns

Other Relevant Information

I confirm I have authority to make this referral and consent to Lamora Healthcare processing this data for care placement purposes in accordance with their Privacy Policy.

✓ Your referral has been received. We will acknowledge it within one working day and contact you to discuss the next steps.