Need Social Care?

Visit our Contact Centres
or write to:
Social Care, PO Box 585,
Worcester WR4 4AD
or call: 0845 607 2000
or fax: 01905 768056
or txt: 07939 572850
or: email Social Care

Location: Home » Social Care » Social Care » Older People » Help to claim benefits » Referral Form

Benefit and Contributions Assessment Referral

Please use this form to refer individuals for information and advice, including home visits assessing their financial needs and entitlement to a variety of financial benefits, as mentioned on the previous page. If the individual is in need of social care, please contact the Worcestershire Hub on 0845 607 2000 or use the any of the other contact details provided on the left hand side of this page. Thank-you.

Customer Details
Title

First name(s)

Surname

NINO

Date of birth

Address 1

Address 2

Town / City

Postcode

Partner Details
Is there a partner at the address?

Title

First name(s)

Surname

NINO

Date of birth

Address 1

Address 2

Town / City

Postcode

Please state who should be contacted to arrange the visit (if different from above)
Name

Relationship to Customer

Contact Tel No.

Please state if there are any special circumstances or requirements

Does the customer have savings

If couple - do they have savings over £44,500

Customer Consent: Please refer to Note 1 below
Verbal Consent given

Referral Details
Name of person sending referral

Date

Contact No.

Email address

Organisation

Note 1 - Internal Use Only
(Verbal Consent is to be obtained from the customer)

In Worcestershire the County Council The Pension Service (DWP) and your local District Council are working together to provide you
with a streamlined service.
Are you happy for us to share your information between these agencies?

Page Information:
Last modification: 10:51:15, 26th November, 2008 by
Review date: 07th December, 2008