Referral & Pre-Admission Form

Please complete all sections. If you have any problems you can contact us or download the form at the bottom of the page.

    Referrer’s Details

    Service User’s Details

    Patient’s NHS Details

    Current Placement

    Funder’s Details

    Additional Information

    If there are any Tribunal, CPA, Forensic or Social Circumstances reports available, please upload them with this form.

    Upload Report

    Confirmation

    By submitting this form you are confirming that the above infomation is correct and all relevant reports have been included for the submission to be reviewed.

    Having Problems?

    If you have any problems with our online form you can download the form below. Please return the form to St Matthews Healthcare Admissions Service:

    Email: commissioning@smhc.uk.com
    Tel: 01604 844 192 | Fax: 01604 850 810

    Download Form