Lufthansa Care
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Referral Request
Referral
Request
1. Referrer Details
Name
Relationship to Client
Select
Self
Family
GP
Hospital
Social Worker
Other
If Other, please specify
Contact Number
Email (if applicable)
Date of Referral
2. Client Details
Full Name
Date of Birth
Phone Number
Address
Living Situation
Alone
With Others
Supported Housing
Preferred Language
Interpreter Needed?
Yes
No
3. Reason for Referral
4. Support Needed
Personal Care
Medication
Meals
Mobility Support
Companionship
Mental Health/Dementia
Overnight Care
Other
5. Consent
Client has consented to referral
Best interest decision (if client lacks capacity)
6. Referrer Signature
Signature
Date
Submit Referral
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