Completing a Home Shield referral form

Home Shield will be discontinued from 12 April 2019

Please be aware that Home Shield now only offers limited support in several areas. In the North area of the county we are no longer able to offer provision for key safes (question 7), staying well at home during cold weather (question 14) or handy person services (question 16) for the over 65s. 

Remember Home Shield is a signposting scheme only and does not assess or deliver services to customers on behalf of its partners.

Complete the Home Shield referral form

When filling it in:

  • Remember this is a professional-led referral scheme. Referrals from members of the public or unrecognised bodies will not be accepted
  • Always complete the web form with details of the person being referred
  • Always complete the web form with your details as a referrer, ensuring your contact details are correct before sending
  • Ensure you have confirmation of consent from the person being referred. Blank or incorrect forms will be rejected by Home Shield partners
  • Remember all information requested will be sent directly to the individual to review and make contact with partners and agencies 
  • You should always leave a copy of the Home Shield public information leaflet with the person you are referring

The main part of the form is divided into four sections, depending on the needs of the person being referred.  You only need to complete the parts of the form which indicate what the person needs help with.

Paper forms

We are no longer accepting paper referral forms.

If you have any questions or queries, email us at

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