CONNECT FOR HEALTH - GP/Authority Referral Form (Access Community Trust)

SOCIAL PRESCRIBING: A new way of working with YOU

We know that taking care of your health involves more than just medicine. With Connect for Health you can get specialist support for more than medical issues.

The details you provide us with remain are securely stored so that we can work with you to provide the best solutions for the client.

You can alternatively email connectforhealth1@accessct.org if you wish.

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* 1. Contact Details:

Client Name

Client Address 1

Client Address 2

Town

Suffolk

Postcode

Client Email Address

Client Phone Number

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* 2. What GP practice is the client registered with?

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* 3. Client's preferred contact method:

Telephone (Call)

Telephone (Text Message)

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* 4. Client Date of Birth:

Please confirm your birth date

Date

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* 5. Client Gender:

Male

Female

Other (please specify)

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* 6. Ethnicity of Client

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other (please specify)

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* 7. Referral reason: (The below are some of the number of things we can help you with)

Weight Management

Physical Activity Support

Healthy Eat

Smoking/Drug/Alcohol/Other Addictive Behaviours

Anxiety/Stress/Depression/Low Mood

Social Isolation

Learning/Training/Employment

Money/Debt/Benefits

Housing Issues

Bereavement

Carer

Other (please specify)

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* 8. REASON FOR REFERRAL: (Include all relevant information, including other agencies involved and state any health and safety risk)

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* 9. Is there anything else we should know prior to booking a one-to-one appoint with this Client?

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* 10. Does the Client have any long term conditions/disabilities that we need to be made aware of?

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* 11. Details of the Referrer:

Referring Agency/Organisation

Referrer Name

Referrer Position

Referrer Email

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* 12. Is the Client a frequent attender for your services?

Yes

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* 13. I confirm that as the Referrer, I have discussed this referral with the Client and have their permission to pass on relevant health information about them?

Yes