Referral for Telecare

Please complete this form to apply for Basic Telecare which consists of:

A base unit which is connected to your telephone line and a nearby electrical socket

A small waterproof red button which can be pressed to call for help

If Enhanced Telecare, such as bed sensors or door sensors, is required please contact your local Adult Social Care team. Their contact details can be found by visiting: https://www.nhshighland.scot.nhs.uk/your-services/all-services-a-z/integrated-teams/#HighlandAdultSocialCareteamcontacts (opens in a new tab)

Before you begin, please check that you are eligible for the service as you cannot complete the form otherwise. To be eligible, you must have:

A mobile signal OR a working telephone line that can make outgoing calls and receive incoming calls.
Preferably 3 responders, but at minimum 2, who live at different addresses and can attend your property within 30 minutes.

There is a charge for the service, but it may be free for certain circumstances such as low income, client is recieving palliative care, or if the client is under 18.

You won't be able to save this form as you complete it, so please ensure you have all the necessary information ready. This includes client details, GP information, responder details (name, address, phone numbers, and email address), as well as next of kin details.

Contacts

Caithness - 03458 509413
Sutherland - 01408 664018
East Ross - 01349 853131
Mid Ross - 01349 860460
Lochaber - 01397 709832
Inverness - 01463 888333
Nairn - 01667 422702
Badenoch & Strathspey - 01479 812618
Skye, Lochalsh & Wester Ross - 01471 820174

Start Referral

Required fields are marked with an asterisk (*)

Referral Details

To enable NHS Highland to provide the Telecare Service, your details will be shared with your local Care & Repair Service, who are contracted to install and maintain the Telecare Service.

* Could you please confirm that you (the client) are happy for this to happen?

* Are you applying for yourself or someone else?

Client details

* Title * First name * Last name * Gender * Date of birth * Address * Postcode (at least 6 characters) * How would you describe your ethnic group? * What is your preferred language to speak with? * What is your preferred language for written correspondence? * Do you live alone?

* Telephone Number ?

* Phone line type ?

* Who is your communication provider?

* Do you have broadband?

Mobile number Email Address

* Do you have at least two responders who live at separate households?

* Would you like someone else living in the home to also have a telecare service?

* Title * First name * Last name * Gender * Date of birth * Address * Postcode (at least 6 characters) * How would you describe your ethnic group? * What is your preferred language to speak with? * What is your preferred language for written correspondence? * Do you live alone?

* Telephone Number

Mobile number Email Address

* Is the client aware that there may be a charge for the telecare service? ?

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Referral for Telecare

Required fields are marked with an asterisk (*)

Referral Details

* Who prompted you to apply for telecare? More Info

* What is the main reason for the referral? More Info

* Where did you hear about telecare?

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Referral for Telecare

Required fields are marked with an asterisk (*)

Health Information

* Client 1 - Please click here to enter details

* GP name ? * Practice address * Practice telephone number

* Please select any health conditions or important information that is relevant for the Highland Hub or the emergency services to be aware of. Use the 'Additional Health Information' box to expand as necessary. ?

Additional health related information

* Would you be able to hear a smoke alarm whilst in bed sleeping? ?

* Does the client receive care at home?

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Referral for Telecare

Required fields are marked with an asterisk (*)

Property Details

* Type of property

* Number of bedrooms

* Tenure of household?

* Property owners name

* Where would you like the telecare box to be positioned?

* Does the property have a keysafe? ?

* Would you like someone other than the client to be the contact for installation?

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Referral for Telecare

Required fields are marked with an asterisk (*)

Responders Details

The safety and wellbeing of the client is dependent on the reliability and capacity of the people who act as responders.
It is essential that responders have this capacity in terms if physical health and availability (day and night),
and are aware of their responsibilities as responders.

Additionally responders must be keyholders or have access to a key through a keysafe.

Please list responders below in the order that they should be contacted in the event of an alarm activation

* Can you please confirm that all responders have agreed and are willing to be a responders?

* Responder 1 - Please click here to enter details

* Relationship to client * Title * First name * Last name * Address * Postcode (at least 6 characters)

* Please enter at least one contact number

Home number Work number 1 Work number 2 Mobile number 1 Mobile number 2 Email Address

* Can this responder reach the client's home within 30 minutes?

* Responder 2 - Please click here to enter details

* Relationship to client * Title * First name * Last name * Address * Postcode (at least 6 characters)

* Please enter at least one contact number

Home number Work number 1 Work number 2 Mobile number 1 Mobile number 2 Email Address

* Can this responder reach the client's home within 30 minutes?

Responder 3 - Please click here to enter details

Relationship to client Title First name Last name Address Postcode (at least 6 characters)

* Please enter at least one contact number

Home number Work number 1 Work number 2 Mobile number 1 Mobile number 2 Email Address

Can this responder reach the client's home within 30 minutes?

Would you like to add additional responders?

Risk Assessment

* Does the client have a responder that is able to respond within 30 mins?

Next of Kin

* Next of Kin - Client 1 - Please click here to enter details

* Who is the client's next of kin?

Please provide any additional information that may be helpful for the monitoring centre. This could include the client's typical times away from home, times of caregiver visits, and whether someone else resides in the property. Providing this information will assist the Hub operator in handling telecare alarm calls.

Previous Submit

Thank you for submitting a telecare referral, this will now be processed by the TEC team.

The local HandyPerson Scheme will be in touch with you to arrange a suitable time for the telecare installation.

Referral for Telecare

Referral Details

Referrer Details

Client details

Referral for Telecare

Referral Details

Referral for Telecare

Health Information

Referral for Telecare

Property Details

Referral for Telecare

Responders Details

The safety and wellbeing of the client is dependent on the reliability and capacity of the people who act as responders.
It is essential that responders have this capacity in terms if physical health and availability (day and night),
and are aware of their responsibilities as responders.

Additionally responders must be keyholders or have access to a key through a keysafe.

Please list responders below in the order that they should be contacted in the event of an alarm activation

Risk Assessment

Next of Kin

Thank you for submitting a telecare referral, this will now be processed by the TEC team.

The local HandyPerson Scheme will be in touch with you to arrange a suitable time for the telecare installation.

If you urgently need telecare (i.e. required for hospital discharge) please contact the TEC team on 01478 614211.

Referral for Telecare

Referral Details

Referrer Details

Client details

Referral for Telecare

Referral Details

Referral for Telecare

Health Information

Referral for Telecare

Property Details

Referral for Telecare

Responders Details

The safety and wellbeing of the client is dependent on the reliability and capacity of the people who act as responders. It is essential that responders have this capacity in terms if physical health and availability (day and night), and are aware of their responsibilities as responders.

Additionally responders must be keyholders or have access to a key through a keysafe.

Please list responders below in the order that they should be contacted in the event of an alarm activation

Risk Assessment

Next of Kin

Thank you for submitting a telecare referral, this will now be processed by the TEC team. The local HandyPerson Scheme will be in touch with you to arrange a suitable time for the telecare installation.

If you urgently need telecare (i.e. required for hospital discharge) please contact the TEC team on 01478 614211.

Error

Information

The safety and wellbeing of the client is dependent on the reliability and capacity of the people who act as responders.
It is essential that responders have this capacity in terms if physical health and availability (day and night),
and are aware of their responsibilities as responders.

Thank you for submitting a telecare referral, this will now be processed by the TEC team.

The local HandyPerson Scheme will be in touch with you to arrange a suitable time for the telecare installation.