Forest of Dean Community Wellbeing Service (Social Prescribing) Referral

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

GP surgery:<Organisation Details>

Patient name: <Patient Name>NHS Number: <NHS Number>

Gender: <Gender>Date of birth: <Date of birth>

I recommend for the above patient to receive advice and/or social prescriptions from the Gloucestershire Community Wellbeing Servicein order to receive support and onward signposting/referralto appropriate local agency(ies). I confirm that I have assessed this patient and to my knowledge there is no medical reason why he/she should not participate. I confirm that I have discussed this referral, and the reasoning for it, with the patient.

Referrer: <Sender Name>Role:

Date: <Todays date> Organisation:

Part B – Referral Information(to be completed by referrer)

Support required in relation to (mark with an ‘X’ as many boxes as apply):

Mental health and wellbeing
Social isolation
General health and fitness
Housing / environment
Long Term Health Conditions
Debt / Finance
Other (please state)

Please provide any further information which may be taken into account when recommending the patient to an appropriate local support agency.

Part C – Patient Consent

I consent to participation in the Community Wellbeing service, the nature and 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 Community Wellbeing service to relevant local support agencies (e.g. memory clubs, lunch clubs, community transport groups) to whom I am referred/signposted. I understand this information will be treated as confidential (although it may be used in anonymous form for statistical or research purposes) and that the data controllers are my referrer. I understand 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 permission for my GP (and referrer where different) to be kept informed of my progress.

Written consent or please tick to indicate verbal consent.

Patient Signature: / …………………………Consent Box
Date: / <Todays date>
Address: / <Patient Address>
Telephone: / <Patient Contact Details>
Email (optional): / <Patient Contact Details>

Instructions for referrer:

Please send toyour Community Wellbeing service using . For enquiriescall: 01594 812447.

Identifier Number:
(to be completed by coordinator)

As at 05/10/2017