NHS Continuing Healthcare assessment request: Southampton

Please complete the form below to request an NHS Continuing Healthcare assessment.

Important Information:

This form is for clients registered with a Southampton GP only.

If the individual is based in Hampshire, Isle of Wight, or Portsmouth, please follow your local referral process.

NHS number Required

Full name Required

Date of birth Required

Current location and home address if different Required

Address 1

Address 2

City

Country

County

Postal Code

Contact telephone number Required

Name of current GP practice Required

Any current care providers

Does the person to be assessed have a learning disability?

Yes

Is the person to be assessed currently funded by the local authority?

Yes

If you hold Power of Attorney please send a copy via email or provide access code

Full name of the person submitting the form Required

Contact email address Required

I agree to the privacy policy

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