Personal Details

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

Health and Wellbeing

Getting Social




Specific Support

Additional Information


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:

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

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.