<p>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 </p><p>Part A – Referrer Consent (to be completed by referrer)</p><p>GP surgery: <Organisation Details></p><p>Patient name: <Patient Name> NHS Number: <NHS Number> Part C – Patient Consent I consent to participation in the Community Connector service, the nature and Gender: <Gender> Date of birth: <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: <Sender Name> permission for my GP (and referrer where different) to be kept informed of my Date: <Todays date> progress. </p><p>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: <Todays date> Mental health and wellbeing Address: <Patient Address> Social isolation Telephone: <Patient Contact Details> Email (optional): <Patient Contact Details> 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) </p>