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 Status*

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

Job Coaching and Skills

Adult Learning

Volunteering

Housing

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

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

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

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.*