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

Housing Type

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

Health and Wellbeing

Falls and Strength & Balance

Living with Dementia (Formal Diagnosis Required)

Visual Impairment

Support with Managing Stress, Anxiety or Low Mood (Southwark Only)

Unintentional Weight Loss or Poor Diet

Food Delivery

Stopping Smoking

Alcohol/Substance Misuse

Experiences of Health Services (Southwark Only)

Social Connections

Lunch Clubs

Exercise Classes

Feeling Lonely/Looking for Groups

Help with IT/Internet

Access to Transport

Befriending

Adult Learning

Housing

Adaptations in the Bathroom

Adaptations in the Kitchen

Adaptations on the stairs

Repairs/Maintenance Advice

Small Odd Jobs

Fire Safety Check and Free Smoke Alarm

Keeping Warm and Well

Care and Other Support

Pendant Alarm and Other Safety Equipment

Filling in Forms

Benefits Review/Applying for Benefits

Trouble Paying Bills

Caring For Someone

Victim of Scams

Home Security or Police Advice

Additional Information

For example, important notes about the current situation, significant health conditions, known risks etc

Additional Information

Consent

In signing this form, you consent to the information on it being stored and shared within the SAIL Partnership. SAIL is a service provided by Age UK Lewisham and Southwark (AUKLS). AUKLS may contact you to discuss potential support and agree with you on referrals to other services, if appropriate.

Date You’re Completing This Form:

IMPORTANT: Please tick this box to confirm the above statement has been read to and agreed by the client

Please tick if applicable

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

Referrer Name

Referrer Organisation

Referrer Contact Number

Referrer Email Address