Dear Sirs,

Direct Care Service from Crossroads Care – South Thames

Thank you for enquiring about the Crossroads Care - South Thames Private
Care Service. Attached herewith is a referral form and our list of charges for
your perusal. We hope it proves of interest.

We provide direct care services at an hourly rate through Crossroads Care -

South Thames Private Care, operating to a very high standard. Our aim for
Private Care is to meet the needs of carers who wish to purchase additional or
individual hours of care support.

If you require the service please return the form and I will arrange to visit you
at home to discuss our range of services and your needs. At this visit a
service plan including a personal care plan will be written. There is no charge
for this part of the service.

You are also very welcome to contact us on the above number or e-mail
address if you have any further enquiries.

I look forward to hearing from you

Yours faithfully

Rona Bourke
Operations Manager
 CROSSROADS CARE p SOUTH THAMES
Direct Care Service

REFERRAL FORM

PERSON REQUIRING CARE

Name: DISABILITY__________________________________________

Address:

Contact Nos:

D.O.B. Age:

Ethnic Origin: Religion: Mental Health:

PRIMARY CARER

Name: D.O.B: Age:

Address:

Contact Nos:

Employment::

Ethnic Origin: Religion:

Health:

Length of time Caring: Relationship to person cared for:

&$5(5¶61(('6

______________________________________________________________________________________________

OTHER SUPPORT:

SECONDARY CARER: NAME:

ADDRESS

Contact
Nos:_______________________________________________________________________________________

G.P.Address:

Telephone No:

SOURCE of REFERRAL

Name: Occupation

Address: Telephone No:

______________________________________________________________________________________________

Date of Referral: Date Visited

Advised of Help to be given? Yes/No Date: Date Commenced:



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