Make a Referral

Thank you for referring to Community Connections Lewisham.

Our current wait time is six weeks. If you require support more quickly, we recommend calling us as you will get help straight away. Our number is 0330 058 3464 and we’re open Monday to Friday, 9.30am-4pm.

The following questions will help you to decide if we are the right service to refer to.

Community Connections Lewisham is not an emergency service so should not be contacted for urgent issues. If you’re worried about someone’s safety or welfare, contact Lewisham Adult Social Care on 0208 314 7777 or email them at Gateway@lewisham.gov.uk. In an emergency, always dial 999.

If you have any questions about a referral or the support we can provide, please call us on 0330 058 3464

Community Connections Referral Form

- Step 1 of 6

Did your client consent to this referral and have they agreed they want all the support being requested? *

PLEASE SEEK CONSENT BEFORE REFERRING AND/OR CHECK THE CLIENT WANTS THE SUPPORT YOU ARE REQUESTING FOR THEM

If your client can self-refer, we recommend they call us directly on 0330 058 3464, where they will receive support and advice immediately.

Are you referring into our new Prostate Cancer Pathway Project? *

Yes
No
Unsure

To find out more about the Project, please select 'Unsure' and it will provide a link with more information to help you decide if this service would be useful.

Community Connections Lewisham is leading on an exciting new project supporting Lewisham residents who are receiving treatment for Prostate Cancer.

You can learn more about the service and whether it would be appropriate here.

Is the client willing and able to engage with our Social Prescribing service currently? *

Yes
No / Unsure

Please note, clients experiencing complex mental health crises, suicidal ideations and other very challenging situations may not be in the right frame of mind to engage with us at this time.

If the person isn’t able to work with us at this time, there is a lot of information on services and support available in our Community Directory.

If you’re unsure if a referral is suitable, please call us to discuss, on 0330 058 3464

Is this referral for support with one of the following? *

Housing
Personal Assistance / Long-Term Support
Benefits Advice & Applications
Community Connections Transport Service
Community Connections Befriending Service
Other

Please note we can't provide support with these topics ourselves, but here are some links to organisations that can:

Community Directory

Lewisham Adult Social Care

Advice Lewisham

Community Advice Works

Age UK Information & Advice

Entitled To Website

If there is other support the client needs, please continue the referral

Please note there are separate referral forms for Community Connections Transport and Befriending Services:

Community Connections Transport Form

Community Connections Befriending Form

If there is other support the client needs, please continue the referral

Is your client able to have a conversation with us in English? *

Yes
No / Unsure

We are small charity and are unable to provide a translator – please consider that our support may be limited if the person doesn’t have a friend/family member/professional to support with translation

Please call us on 0330 058 3464 if you would like to discuss further

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

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

SECTION 1 - REFERRER DETAILS

Please complete this section if you are making a referral on behalf of another person.

Referrer Name

Referrer Contact Number

Referrer Email Address

Referrer Organisation/Type

Please select the appropriate category/organisation name. If none apply then please select 'Other'.

Is there anything else you'd like to tell us about where you are referring from?

SECTION 2 - DETAILS OF THE PERSON SEEKING SUPPORT

Title

Name *

First

Last

Main contact number *

Alternative Contact Number (if known)

Email address

*Please Note- if you are referring yourself and would like to receive an email confirmation of this referral then please enter your email address in Section 1 above in the box entitled 'Referrer Email Address'.

Preferred method of contact *

Address Line 1 *

Address Line 2 *

Address Line 3

Postcode *

Date of birth *

Please fill in as DD/MM/YYYY

Gender *

Male
Female
Non-binary
Not disclosed

Any further information you'd like to tell us about the person's gender identity?

Ethnicity *

Please select one from the dropdown list above

GP Surgery *

If you do not have this information please select ' Unknown'.

SECTION 3 - NEXT OF KIN DETAILS

Please provide Next of Kin details if the person consents, and it may be useful for us to contact them to discuss the referral.

Your Next of Kin

First

Last

Is the Next of Kin the first person we should contact about the client? (Yes or No)

Next of Kin relationship to the person needing support

Next of Kin contact number

Next of Kin email address

SECTION 4 - GETTING SOCIAL / MEETING NEW PEOPLE

This is for people who are keen to take part in social activities and groups in their local area and meet new people. Please select any of the following you may be interested in:

GETTING SOCIAL / MEETING NEW PEOPLE

Access to Transport Schemes (Taxicard, Dial-A-Ride etc)
Adult Learning
Arts & Crafts
Befriending
Community Connections Transport Service
Exercise
Gardening
Help with IT / Using the Internet
Learning new skills
Social Groups
Volunteering

Is there anything you're particularly interested in finding out more about or trying? Please let us know more here:

SECTION 5 - INFORMATION AND SIGNPOSTING

This is for people who need support and advice on any of the following topics. Please ensure the person has agreed to hear from us on all the items you select:

HEALTH SERVICES

Alcohol or substance misuse
Falls, strengths & balance classes (65+)
Help with diet / healthy eating
Learning disabilities support
Living with a dementia diagnosis
Looking after your mental health
Pendant Alarm and other monitored safety equipment
Stopping smoking
Toenail cutting
Visual impairment

PRACTICAL SUPPORT

Adaptions to keep you safe
Discrimination support (BAME, LGBTQIA+ etc)
Domestic violence support
Fire Brigade safety check
Home security / Police advice
Support for Carers
Support with homelessness
Support accessing free/low-cost food
Support accessing equipment for 0-5 year olds
Support with energy bills

Please let us know what support you are looking for: *

Is there anything that may affect us providing that support? *

For example, do you have any relevant medical conditions? Are you housebound? Are you or someone you know able to discuss your needs with us in English? Please note we don’t have translation services. Are you under any judicial restrictions?

Are there any risks or considerations to our staff if they visit you in your home? *

For example, is your home wheelchair accessible? Do you have any pets? Are there other people living with you?

Date you are completing this form *

Where did you hear about Community Connections Lewisham? *

Is there anything else you'd like to tell us about where you heard about us?