Personal Details

First Name*

Surname*

Date of Birth*

Gender*

Ethnicity*

GP Surgery

Address line 1*

Address line 2

Address line 3

Address line 4 (Town)

Address line 5 (County)

Postcode*

Main Contact Number*

Other Contact Number

Email Address (Main)

Preferred Method of Contact*

With their consent, we can contact a relative or friend on behalf of the above. Please enter their details below.

Next of Kin Name

Next of Kin Relationship

Next of Kin Contact Number

Next of Kin Email Address

Health and Wellbeing

Looking After Your Mental Health

Exercise Groups, Classes and Walks

Help With Diet/Healthy Eating

Food Delivery (50+)

Stopping Smoking

Alcohol or Substance Misuse

Getting Social

Feeling Lonely / Looking for Groups

Befriending

Access to Transport

Help with IT / Internet

Finances

Benefits Review

Applying for Benefits

Trouble Paying Bills

Energy Bills Review

Safety

Fire Brigade Safety Check and Free Smoke Alarm

Home Security or Police Advice

Pendant Alarm and Other Monitored Safety Equipment

Victim Support

Discrimination Support (BAME, LGTBQ, Gender)

Careers

Life Skills

Adult Learning

Become A Volunteer

Adaptations to Keep You Safe

Support with Homelessness

Odd Jobs

Specific Support

Living With a Dementia Diagnosis

Living With a Long Term Condition

Falls and Strength and Balance Classes (65+)

Learning Disabilities Support

Support for Carers

Visual Impairments

Additional Information

Please summarise briefly the reason for this referral and if there is any additional information you think we should be aware of. Please include information on any relevant medical conditions and if you are currently receiving support from any other professional organisations.

Are there any risks posed to our staff if they visit you at home?

Consent

In order to help you, we need to store information about you. The law says that we must get your consent to do this. Everything you tell us will be treated confidentially and your data will be subject to the Data Protection Act 2018. Records will be kept securely for 6 years and then securely destroyed.

For more information, please follow: https://lewisham.gov.uk/about-this-site/privacy/community-services/adult-social-care-privacy-statements/privacy-notice---adult-social-care

I consent to Community Connection (Age UK Lewisham and Southwark) recording:

Personal and sensitive information about me:

Because we may need to speak to other people in order to help you, we need to ask for your consent to speak on your behalf.

I consent to Community Connections (Age UK Lewisham and Southwark) making representation on my behalf, and to request and disclose information about me that is relevant to this purpose with third parties such as community voluntary services:

Date you're completing this form*

Where did you hear about Community Connections Lewisham?*

Are you referring on behalf of someone else? If yes, please fill in your details below.*