Referrals

TEC Application form

If you would like to refer yourself or someone you know to our Lifeline Alarm and TEC service please fill out our simple online application form. Once completed, the referral will be processed and contact will be made within 72 hours of receipt.

Register Interest for our other services

To find out more about one of our other services, please fill in the form below. Once completed, the referral will be processed and contact will be made within 72 hours of receipt.

If you are interested in our ‘Hospital to Home Support Service‘ please note that it is extremely useful for ‘On Ward’ patients to express their interest as quickly as possible, so that the transition from ‘Hospital to Home’ can be delivered with maximum effect.

    Client Details

    Which services are you interested in? (please tick all)

    Hospital to Home (please note this is only available to residents in the Surrey Downs CCG area).
    Lifeline Alarm
    TrustID
    Telephone Check In
    Community Transport
    Social Centres
    Meals on Wheels
    Information and advice on local services.


    YesNo


    YesNo

    Referrer Details

    Data Protection Statement

    This referral containing the information you have provided will be passed to Mole Valley District Council, Elmbridge Borough Council, Epsom & Ewell Borough Council, Tandridge District Council, Spelthorne Borough Council or Reigate and Banstead Borough Council according to your residence. The organisations are limited to those and the information you have provided will only be used to allow them to further contact you as necessary to find out more around the support they may be able to provide. Your information will be treated as confidential by Surrey County Council and only used for the expressed purpose above in line with the General Data Protection Regulation. After the referral has been made we will securely hold your information for 12 months before destroying it.

    More details on Mole Valley District Council's commitment to your privacy is available on the website.