This form is for reporting any adults (18 years of age or over) who require support or care for someone living with a serious illness, physical disability, learning disability or a mental health illness. This form must not be used if the person is in any form of immediate danger.

If you feel the person is in immediate danger, please dial 999 in an emergency.

This form is intended for professionals to make a referral to Buckinghamshire Council Adult Social Care for a member of the public.

Please only complete this form if you are a professional