The following webform is for the referral of patients from Lewisham University Hospital to Community Connections Lewisham.

Before completing the form below please make sure you check our eligibility criteria below to ensure we are the appropriate service for your patient. You can also find out more about whether we are the right service for your patient here.

Patient Eligibility Criteria:

• The person you are referring is aged 18 or over and lives in the borough of Lewisham
• You have no concerns about the patient’s mental capacity
• The patient is not currently engaging in regular alcohol or substance misuse

REFERRER DETAILS

Please fill in the following details about yourself so that we can send you feedback on your patient.

Name *

First

Last

Job title

Department

Phone number

Email *

Are there any other health professionals you would like us to keep informed about the patient’s progress? If so please provide their name and contact details here:

PATIENT DETAILS

Please complete all of the details below in order that we can create a client account for this patient within our service

Name *

First

Last

Date of birth *

Please complete as DD/MM/YYYY

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone

Gender *

• Male
• Female
• Non-Binary
• Other

Ethnicity *Arab or Arab BritishAsian 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 - Caribbean Black or Black British – Other Black backgroundLatin American or Latin American BritishMixed – White and AsianMixed – White and Black AfricanMixed – White and Black CaribbeanMixed – Any Other Mixed BackgroundWhite - English/Welsh/Scottish/Irish/BritishWhite – Any other white backgroundOtherPrefer not to say

We collect this information to determine whether we are reaching all of the types of people who live in Lewisham, or only some of them. We need to make sure our service is accessible to every isolated adult who needs it. These questions can be uncomfortable, so you can choose ‘prefer not to say’ for any.

GP Surgery

Location of patient at time of making referral *

Please let us know the current location of your patient, such as 'at home' or the name of their hospital ward

Are they a carer?

• Yes
• No

A carer is anyone who looks after a family member, partner or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without their support. The care they give is unpaid and covers things like cooking meals, washing, helping with personal hygiene, etc.

RELATIVES DETAILS

With their consent we can contact a relative or friend of the patient being referred. If relevant, please enter their details below:

Name

First

Last

Phone

Email

Relationship to patient:

REASONS FOR THIS REFERRAL

Please answer the following question to let us know why you are referring this patient to Community Connections Lewisham.

What activities is your patient interested in to improve their wellbeing?

• Exercise
• Arts & Crafts
• Gardening
• Social groups/meeting new people
• Volunteering/Studying
• Befriending: getting a regular call/visit from a volunteer
• Learning new skills
• Adult education

Tick any that apply

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.

Would your patient 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

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

Please provide any further information you think we should be aware of, such as any relevant medical conditions or if they are being supported by another organisation(s)

Are there any risks posed to our staff if they visit the patient at home? *

CONSENT

IMPORTANT: Please tick this box to confirm the following 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 Community Connections Partnership. Community Connections Lewisham is a service provided by Age UK Lewisham & Southwark (AUKLS). AUKLS will contact you to discuss potential support and agree with you on referrals to other services, if appropriate

Signature (client/referrer) *

Clear Signature

In accordance with DPA 1998 and GDPR you have rights regarding your data, including requesting that we remove your data from our system at any point. For more information please contact AUKLS by emailing information@ageuklands.org.uk or by phoning Community Connections Lewisham on 0330 0583 464.

What happens next?

Once your completed referral is received one of our team will get in touch with the patient (or their NOK if requested) to discuss their support needs further. Please note that CCL is not an emergency service and should not be contacted for urgent issues or confused with Adult Social Care. Due to high demand patients can expect to wait a few weeks before receiving contact from our team.

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