Please ensure you complete all of the information boxes below to enable acceptance of the referral.

Please note, by completing this referral, you confirm that the clinical team will retain clinical responsibility for the patient/service user that this individual cares for a period of 8 weeks and/or the duration of their calls with Check in & Chat.  If the patient/service user is discharged before our calls with them (or the carer) finish, calls may be terminated immediately.

Please be aware that Chatters cannot organise services, hospital appointments and undertake other health and social care activities.  Chatters can only signpost individuals to other services as required.

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Section one: Referral details

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Section two: Individual's details

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