Professional Referrals

Welcome to the Connected Living professionals referral service. Please complete the form below and attach your supporting documents. Your request will be sent to the Connected Living Customer Services team as a priority. If sent outside of our normal working hours, your referral will be actioned the next working day. If you need to speak to a member of the team, please call 0333 400 8299 during our normal office hours.

* required field

Organisation*

Name of Referrer*

Job title / Position held*

Email Address*

Contact number*

Referral code

Has the customer given consent for this to be arranged and their details to be shared with us?*

Customer name*

Customer Address*

Customer Contact number/Emergency Contact number*

(If emergency contact, please add their relationship to the customer, eg family, friend, carer etc)

If applicable, the Serial ID of the Alarm (located on the bottom of the unit above the barcode)

Solution required*

Does the customer have a key safe?

Does the customer need a key safe?

Does the customer need any other equipment?

please provide details

Supporting information

Who will be paying for the equipment?*

Are there any risks that we need to be aware of?*

For example: Is the customer a smoker? Do they have any pets? Are there any potential risks from other people? Do they have any aggression or antisocial behaviours which may or may not be related to mental health issues? Is there anything we need to be aware of in your property?

Allowed files: PDF, DOC, DOCX, GIF, JPG, PNG, MPEG, MP4, AVI, WEBM, MOV, WMV

File size limit: 20MB

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