You can refer yourself for Community Connections Lewisham support using the form below. The wait time is currently six weeks, so if you need support more quickly please call us or visit our weekly Drop In session. 

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. 

Need a benefits check only? We recommend contacting Advice Lewisham directly on 0800 231 5453, which is open: Mondays: 9am-11am & 3pm-5pm,Tuesdays 9am-11am & 3pm -5pm, and Wednesdays 9.30am-11.30am & 3pm-5pm.

N.B. Please do not complete this form using Internet Explorer. Please use a different browser like Google Chrome or Firefox. Using an Ad Blocker can also cause problems, son please turn it off whilst using this form as using one may result in your referral not being received.  

CCL Referral Form

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/TypePlease select from the dropdown listNext of KinFamily memberFriendNeighbour Adult Social CareHousing ProviderChildren and Family CentresOther Lewisham Council organisationGPMental Health services (PMHT, CMHT)University Hospital LewishamGuy's and St Thomas' HospitalKing's College HospitalOther health sector referral 999 ClubAdult Learning LewishamAdvice LewishamAthenaBLG Mind / Lewisham Community WellbeingBlind AidCatbytesCommunity Falls ServiceDementia HubEnableFoodbankGoodGymHappy FeetHumankindIAPTDieteticsLewisham Refugee and Migrant NetworkLinklineLittle VillageLondon Fire BrigadeMETROOccupational Therapy (OT)PLUSSafer Neighbourhood Team (Police)South London Healthy Homes (SELCE)Stop Smoking ServiceSydenham GardenCarers (Your Voice)Voluntary & Community Sector GroupOther

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

Name *

First

Last

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 *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 sayUnknown/Not stated

Please select one from the dropdown list above

Address Line 1 *

Address Line 2 *

Address Line 3

Postcode *

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 *Please select from the dropdown listMain contact numberContact my Next of KinMobile numberTexts onlyEmail onlyLetters only

GP Surgery *Please select from the dropdown listAmersham ValeBaring Road Medical PracticeBellingham Green SurgeryBelmont Hill SurgeryBoundfield Medical Centre (ICO Group)Brockley Road Surgery - Brockley Road Medical CentreBurnt Ash Surgery @ Lee Health CentreChinbrook Surgery (ICO Practice)Clifton RiseDeptford Medical CentreDeptford SurgeryDownham Family Medical PracticeElm Lodge Surgery BromleyHilly Fields Medical CentreHonor Oak Group PracticeHurley Group PracticeKingfisher Medical CentreLee Road SurgeryLewisham Medical CentreMarvels Lane Surgery (ICO Group)Moorside Clinic (ICO Group)The Grove Medical CentreMorden Hill SurgeryMornington SurgeryMuirkirk SurgeryNew Cross Health CentreNightingale Surgery (Lee Health Centre)Nunhead SurgeryOakview Family PracticeOld Kent Road Surgery - 184 Old Kent RoadParkview SurgeryPaxton Green Group PracticeQueens Road PartnershipQueens Road Surgery -136 Meeting House LaneRushey Green Group PracticeSouth Lewisham Group PracticeWaldron Health CentreSt John’s Medical CentreSurgery not listed / Out of areaSydenham Green Group PracticeThe Grove Medical Centre-Windlass PlaceThe Jenner PracticeThe Vale Medical CentreTorridon Road SurgeryTriangle Group PracticeUnknownVesta Road SurgeryWaldron Health CentreWells Park PracticeWinlaton SurgeryWoodlands Health CentreWoolstone Medical Centre

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

Your Next of Kin

First

Last

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

• No
• Yes

Next of Kin relationship to the person needing support

Next of kin contact number

Next of kin email address

SECTION 3 - WHAT TYPES OF SUPPORT ARE NEEDED?

Please tick any relevant boxes from the checklist below.

HEALTH & WELLBEING

• Alcohol or Substance Misuse
• Discrimination Support (BAME, LGBTQ+ etc)
• Exercise Groups, Classes and Walks
• Help with Diet / Healthy Eating
• Looking after your Mental Health
• Stopping Smoking
• Toenail Cutting

GETTING SOCIAL

• Access to Transport Schemes (Taxicard, Dial-A-Ride etc)
• Befriending
• Help with using IT / Accessing the Internet
• Meeting new People / Looking for Social Groups

FINANCES

• Support Accessing Free / Low-Cost Food
• Support for Families
• Support with Energy Bills
• Support with Low Income

SAFETY

• Domestic Violence Support / Violence Against Women and Girls
• Fire Brigade Safety Check and Free Smoke Alarm
• Home Security / Police Advice
• Pendant Alarm and Other Monitored Safety Equipment

LIFELONG LEARNING & EMPLOYABILITY

• Adult Learning
• Become a Volunteer
• Life Skills
• Employment

HOUSING

• Adaptions to Keep You Safe
• Odd Jobs
• Support with Homelessness

SPECIALISED HEALTH SUPPORT

• Falls, Strengths and Balance Classes (65+)
• Learning Disabilities Support
• Living with a Dementia Diagnosis
• Living with a Long-Term Condition
• Support for Carers
• Visual Impairment

Additional Information *

Please summarise briefly the reason for this referral and if there is any additional information you think we should be aware of. Please include information on any relevant medical conditions and if you are currently receiving support from any other professional organisations.

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

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 *

Where did you hear about Community Connections Lewisham? *Please select from the dropdown listOnline searchSocial mediaLeaflet/posterThrough Adult Social CareThrough a GP/Medical ProfessionalAt a local community groupFrom a friend or relativeOther

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