Snap Care Service Provider Referral Form

Service Provider Referral Form

Snap Care is registered as a Data Controller and complies with General Data Protection Regulation (GDPR). We will use the information you provide only in connection with the services provided by us. Any questions before you complete the form? Please just ask, we will be happy to help: 020 7729 2200 .
Please note!
We have submitted our CQC registration application. While this is being processed, we are currently unable to accept clients who require medication administration or personal care, as defined by the Care Quality Commission (CQC).
Referrer Details
Referrer Name*

First NameLast Name
A case managerA client requiring supportDeputy/SolicitorOther
Email*
example@example.com
Phone Number *
Including area code please, if a landline or outside the UK
Company/Organisation if applicable
Client Details:
Client's Full Name*

First NameLast Name
Preferred Name/Known As
Address (Please note 'County' must be completed as an essential field)*

Street Address

Street Address Line 2

CityCounty

Postcode
Address of where support is to be provided - if different to the home address
Client's Date of Birth
Client's Gender
Does the client have capacity?*
If the client does not have capacity, please provide details of the client's representative - e.g. legal deputy.
What interests, hobbies does the client have?
Does the client have any pets?
Next of Kin Details
Next Of Kin Details:

First NameLast Name
Next Of Kin Relationship To The Client
Next of Kin Email
example@example.com
Next Of Kin Phone Number
Including area code please, if a landline or outside the UK
The Client's Needs
Please provide an overview of the client's disability, additional; needs, medical history. Please tell us how the client sustained their injury or disability, including any circumstances you'd like us to be aware of*
Support Requirements
Personal Assistant (PA)Professional Support Worker24-Hour Live-in SupportNight CarerCare Team LeaderBuddyOther
Personal Care (Sorry, we are unable to support clients who require personal care/medical administration until our CQC application has been procecced)Cognitive NeedsBehavioural NeedsSocial, Educational and/or Employment SupportComplex Medical CareCommunicationMoving & HandlingMedication Administration (Sorry, we are unable to support clients who require personal care/medical administration until our CQC application has been procecced)NutritionSocial, Emotional, Mental Health (SEMH)Other
Hours & Days support is required
When would you like someone to start?
What are the ESSENTIAL requirements for this role? (specific experience, qualifications etc)
What are the PREFERRED requirements for this role?
Please let us know the requirements for the Client, including support worker specification, if a driver is required, specific gender, cultural/lifestyle preferences etc.*
If the support required is not on-going, please confirm the length of time required:
Funding
Client's Funder/Fee Payer's Details including Name, Company, Email Address and Invoicing Reference Number where applicable: *
Any other information you feel will be useful for us to know
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Service Provider Referral Form

Referrer Details

Client Details:

Next of Kin Details

The Client's Needs

Support Requirements

Funding