South Cotswolds Social Prescription

Please provide a short summary of any relevant patient background Part A – Referrer Consent (to be completed by GP/Referrer) information / details. Referrer’s details Click here to enter text. Click here to enter text. (e.g. Surgery / ICT or referring organisation name & address) Patient’s Name : Click here to enter text. Patient’s DOB: Click here to enter text. Part C – Patient Consent (to be agreed by patient) I consent to participation in Patient’s NHS number: Click here to enter text. the South Cotswold Social Prescription Service, The nature and purpose of which If not referred from GP, GP Name: Click here to enter text. has been explained by my GP. I consent to the release of relevant personal please give patient’s GP information about myself to the Social Prescription co-ordinator and relevant local name & practice details: GP Practice name: Click here to enter text. support agencies (e.g. memory clubs, lunch clubs, community transport groups) to whom I am signposted. I understand this information will be treated as confidential Date: Gender: Male ☐ Female ☐ Trans ☐ (although it may be used in anonymous form for statistical or research purposes) I recommend for the above patient to be referred to the South Cotswold Locality and that the data controllers are my referring GP practice and Cotswold District Social Prescription Service in order to receive onward signposting to (and support Council. I understand that I have (i) the right to change my mind about being from) appropriate local agency(ies). I confirm that I have assessed this patient referred to the service and to withdraw consent and (ii) right of access to my and to my knowledge there is no medical reason why he/she should not information. I give permission for my GP to be kept informed of my progress. participate. I confirm that I have discussed this referral, and the reasoning for it, with the patient. Patient has consented and agreed to the information above ☐ GP’s / Referrer’s name Name: Click here to enter text. Patient Name Click here to enter text. and date of referral Date: Click here to enter text. Patient Address Click here to enter text. Part B – Referral Information (to be completed by GP/Referrer) Support required in relation to (tick as many boxes as apply):

Mental health and wellbeing ☐ Patient Phone number Click here to enter text. Social isolation ☐ General health and fitness ☐ Patient Email (optional) Click here to enter text. Benefits / housing / environment ☐ Identifier Number (For completion Caring responsibilities ☐ by Cotswold District Council) Memory problems ☐ Please securely email this completed form as per guidance to: Other (please state) Click here to enter text. [email protected] – 01285 623450

To referring Health Professional

As at 21.04.2016 South Cotswolds Social Prescription However, you may wish to refer patients who are accessing these services to the broader range of services and activities Instructions for sending this electronic form by email that can be accessed through the Social Prescription Service.

If you are using nhs.net accounts – this system is secure and you The Social Prescription Service can refer in to a wide can send this completed form without encryption to: range of services and activities, including but not limited [email protected] to:  Memory clubs If an NHS.net account is available within the practice / your  Befriending schemes (including telephone organisation, it must not be a general account used by staff who befriending) would not need to see the referral forms.  Carer respite  Lunch clubs and social activities, clubs and If practices do not have NHS.net accounts they would need to societies ensure all personal and sensitive personal information is contained  Health walks within the attachment which should be encrypted to the NHS  Postural stability and T’ai Chi classes Encryption Standard which is AES 256. Encryption software such as WinZip (paid for) and 7Zip (free) enable encryption to be selected  Benefits and debt advice to this level.  Energy and affordable warmth advice and grants  Assistance with and grants for home adaptations In line with Information Governance, please send the password in a  Crime prevention and security advice separate method of communication – e.g. by telephone.  Neighbour nuisance advice  Volunteering opportunities Thank you for your co-operation  Support groups for specific conditions  Community transport Further Information  IT advice and training

You should continue to refer patients to the following services through existing referral routes, not through the Social Prescription Service:  Falls Clinic  Active Lifestyles (exercise on GP referral scheme)  2gther Trust (mental health or dementia diagnosis)  Turning Point (drug and alcohol recovery)

As at 21.04.2016