Adult Social Care Self-Referral Form

If you are worried about abuse or neglect, please complete the safeguarding referral in the first instance.

To ensure you receive the best possible support that is coordinated and joined-up, we may share or obtain information with wider partners and organisations, or via the GM Integrated Shared Care Record.

This may include health service providers such as GPs, community health teams, and organisations that offer support, like care providers or equipment suppliers (e.g. Ableworld).

Sharing this information helps us deliver the right support at the right time, in a joined-up way. Full details of how data may be used can be found in the Adult Social Care Privacy Notice (opens in new window)  on the Council’s website.

Security time out

For security reasons, you will have 25 minutes to complete each page of this form. After this time, any information entered will not be saved.

We recommend that you gather any information you may need before you start.

During the form, we will ask you for:

  • any previous contact you have had with Adult Social Care or other services
  • any medical conditions, disabilities, or health issues we should be aware of
  • any changes that have led to this request for support
  • what you hope our support will help you achieve