Tel: Tel: 07888 321090

Book Referral

Patient Details (*Mandatory information)

If you would like to find your NHS number follow this link  
Client Contact Preferences
Contact By Phone
Contact By Email
Contact By SMS
Contact By Post
If this client/ Patient has a carer, then please add details below
If applicable, who can we talk to regarding this person (e.g. Power of Attorney)

Reason for Referral *

Long Term Conditions

If you wish to add a Long Term Condition not listed, you can add one using the free text option below.
Long Term Condition (Free Text)

Risk Factors

Referral Information *

Please provide additional details on the context of this referral, including any concerns or comments that may help us support the patient?  

Data Sharing Statement

Social Prescribing Lincolnshire is a service provided by NHS and community-based organisations working together. The aim of the service is to connect people with local community services for information, advice and support.

In order to provide your patient / client with the social prescribing service, the information you give on this form will be shared with local social prescribing service providers and a note of the referral may be added to the patient’s GP records.

We recognise that this form asks for some sensitive information to help us direct your enquiry appropriately.The fields marked * are necessary in order to process the referral.

Your patient / client has rights regarding their personal data, including seeing what data is held, and to make sure it’s accurate and up to date.Their data is stored electronically in a secure, password -protected system called Social RX Connect.Lincolnshire Voluntary Engagement Team(LVET) hosts the Social RX Connect system, and our privacy policy is available on the website:

If you have explained this to your patient/client and they agree to share their information please select Yes below.