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:

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

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* 3. Client's preferred contact method:

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* 4. Client Date of Birth:

Date

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* 5. Client Gender:

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* 6. Ethnicity of Client

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

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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:

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

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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?

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