Ageing Well Southwark SAIL

Personal Details

First Name*

Surname*

Date of Birth*

Gender*

Ethnicity*

Unpaid Carer?*

GP Surgery*

Home Address Line 1*

Home Address Line 2*

Home Address Line 3

Home Address - Town

Home Address - County

Postcode*

Accommodation Type*

Main Contact Number

Alternative Contact Number

Email Address

Preferred Method of Contact (please note we will always contact the person being referred initially)

Does the person have dementia?

Health and Wellbeing

Falls Prevention Exercises

Stress, Anxiety or Low Mood

Healthwatch Southwark

Unintentional Weight Loss

Alcohol or Substance Misuse

Toe Nail Cutting

Money Advice

Benefit Queries

Trouble Paying Bills

Paying for Care

Filling in Forms

Social

Groups & Activities

Exercise Classes

Volunteering

Befriending

Technology Skills

Accessing Transport

Care and Support

Unpaid Care Responsibilities

Support with a Dementia Diagnosis

Visual Impairment

Support With Decision Making for Health and Care

Housing

Home adaptations and equipment

Equipment to Support Sensory Impairment

Pendant Alarm

Monitored Sensors or Reminders

Housing Advice

Handyperson

Home Safety

Home Security

Home Fire Safety Check

Victim of Scams

Additional information

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

Consent

By signing and / or ticking this form, you accept that the information provided will be stored electronically and shared with the COPSINS and Ageing Well Southwark partners as listed below. The sharing of information will enable us to more effectively work to support you to access the services you have identified in this form.

The COPSINS and Ageing Well Southwark partners are Age UK Lewisham and Southwark, Blackfriars Settlement, Link Age Southwark, Southwark Carers, Southwark Pensioners’ Centre, Time and Talents and the London Borough of Southwark’s Adult Social Care Customer Service Team.

IMPORTANT: please confirm that the above statement has been read to and agreed by the client*

Date You’re Completing This Form:*

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