Thank you for visiting Community Connections Lewisham’s Patient Self-Referral page! We look forward to speaking with you.

Please complete the online form below to let us know what types of health and wellbeing support you would be interested in. Once we have received your completed form our team will get in touch.

You can also call our phoneline (0330 0583 464) open Monday-Friday 9:30am-4pm, or come and meet us in person at our weekly drop-in, held every Thursday 2-4pm at PLACE/Ladywell, Unit C, 261 Lewisham High Street, SE13 6NJ.

A & E Patient Self-Referral Form

ABOUT YOU

Your Name *

First

Last

Date of birth *

Please enter as DD/MM/YYYY

Gender *

• Male
• Female
• Non-binary
• Not disclosed

Ethnicity *Unknown/Not stated ArabAsian or Asian British - BangladeshiAsian or Asian British - ChineseAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - Other Asian backgroundBlack or Black British - AfricanBlack or Black British - CaribbeanBlack or Black British - Other Black backgroundLatin AmericanMixed - White and AsianMixed - White and Black AfricanMixed - White and Black CaribbeanMixed - Any other Mixed backgroundWhite - BritishWhite - Other White backgroundIrishRoma Gypsy or Traveller of Irish HeritageOther - Any other Ethnic groupPrefer not to say

Please select one from the dropdown list above

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Telephone Number

Email

Preferred method of contact *PhoneEmailText messageLetter

NEXT OF KIN DETAILS

If you prefer, we can make contact with your Next of Kin (family member or close friend), provided they have given their permission.

If so, please provide their full name, contact details and their relationship to you in the box below.

HOW IS YOUR WELLBEING AT PRESENT?

Please tell us how you are doing currently by answering the multiple choice questions below. You can leave these blank if you prefer not to say.

Would you say that you feel lonely?

• Never
• Rarely
• Sometimes
• Often
• Always

Would you say that you feel good about yourself?

• Never
• Rarely
• Sometimes
• Often
• Always

Would you say that you deal with problems well?

• Never
• Rarely
• Sometimes
• Often
• Always

Would you say that you are interested in exploring new things?

• Never
• Rarely
• Sometimes
• Often
• Always

Would you say that you are optimistic about the future?

• Never
• Rarely
• Sometimes
• Often
• Always

Do you feel like you know about what services are available in Lewisham?

• I am not interested
• I don't know much but would like to find out
• I know quite a lot and I’m interested to find out more
• I know most things and can signpost other people

WHAT CHANGES WOULD YOU LIKE TO MAKE?

Please answer the following questions to tell us about your interests, support needs and/or any changes you wish to make in your life.

What activities would you be interested in to improve your wellbeing?

• Exercise
• Arts & Crafts
• Gardening
• Social Groups/Meeting new people
• Volunteering
• Befriending: Getting a regular call/visit from a volunteer
• Learning new skills
• Adult education

Tick any that apply to you

Please tell us more about your selections above by giving some specific examples e.g. a specific skill they'd like to learn, type of exercise they want to try, or a particular type of group they're interested in joining etc. (*you can leave this space blank if you are not sure)

Would you like support with any of the following?

• Living with a long-term condition
• Support with low income and energy bills
• Support with homelessness
• Support for families
• Support with caring responsibilities
• Mental health support
• Stop smoking support
• Alcohol and substance misuse support
• Domestic violence support
• Applying for community transport schemes
• Support with IT/internet access
• Employability support

Tick any that apply to you

Is there anything else you want to tell us to describe your situation?

CONSENT - I consent to Community Connections Lewisham (Age UK Lewisham and Southwark) recording personal and sensitive information about me: * *

• YES
• NO

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 visit our website at http://www.communityconnectionslewisham.org

Date you are completing this form

Please fill in the date as DD/MM/YYYY

Submit