Gloucestershire Community Connector and Social Prescription Referral

Gloucestershire Community Connector and Please provide any further information which may be taken into account when recommending the patient to an appropriate local support agency. Social Prescription Referral

Part A – Referrer Consent (to be completed by referrer)

GP surgery:

Patient name: NHS Number: Part C – Patient Consent I consent to participation in the Community Connector service, the nature and Gender: Date of birth: purpose of which has been explained by my health or social care referrer. I consent to the release of relevant personal information about myself by the I recommend for the above patient to receive advice and/or social Community Connector service to relevant local support agencies (e.g. prescriptions from the Gloucestershire Community Connector Service in order memory clubs, lunch clubs, community transport groups) to whom I am to receive support and onward signposting/referral to appropriate local referred/signposted. I understand this information will be treated as agency(ies). I confirm that I have assessed this patient and to my knowledge confidential (although it may be used in anonymous form for statistical or there is no medical reason why he/she should not participate. I confirm that I research purposes) and that the data controllers are my referrer. I understand have discussed this referral, and the reasoning for it, with the patient. that I have (i) the right to change my mind about being referred to the service and to withdraw consent and (ii) right of access to my information. I give Referrer: permission for my GP (and referrer where different) to be kept informed of my Date: progress.

Part B – Referral Information (to be completed by referrer) Patient Signature: …………………………………… Support required in relation to (mark with an ‘X’ as many boxes as apply): Date: Mental health and wellbeing Address: Social isolation Telephone: Email (optional): General health and fitness Instructions for referrer: Housing / environment Please send to your Community Connector service using nhs.net email. Long Term Health Conditions Identifier Number: Debt / Finance (to be completed by coordinator) Other (please state)