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

Please enter as DD/MM/YYYY
Please select one from the dropdown list above

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.

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.

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.
Tick any that apply to you
Tick any that apply to you
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
Please fill in the date as DD/MM/YYYY