Social Prescribing Referral

Tel: Tel: 07888 321090
Email: hello@lvet.org

Book Referral

Lead Provider

Referral Date*

GP Practice*

No GP/GP Out of Area?

Patient's GP (if known)

Your Details (*Mandatory fields)

Title

First Name*

Surname*

Date Of Birth (DD/MM/YYYY) *

NHS Number
If you would like to find your NHS number follow this link

Telephone*

Mobile

Address Line 1*

Address Line 2

City

County

Postcode

No Fixed Abode

Client Contact Preferences

Contact By Phone

YesNo

Contact By Email

YesNo

Contact By SMS

YesNo

Contact By Post

YesNo

Is this Patient/ Client a carer?

If this client/ Patient has a carer, then please add details below

Carer First name

Carer Surname

Telephone

Mobile

If applicable, who can we talk to regarding this person (e.g. Power of Attorney)

Alternative Trusted Contact Name

Alternative Trusted Contact Details (Phone/Email)

Reason for Referral *

BereavementChange in circumstanceFinances
Health Coach support - behaviour change/lifestyleHealth Coach support - long term conditionHousing
Low confidence/self esteemMental Health ConditionOther (Please include in referral information)
Physical healthRepeat appointments with unexplained reasonsSocial isolation

Long Term Conditions

ArthritisAsthmaChronic kidney disease
Chronic liver diseaseCOPDDementia
Epilepsy HypertensionLearning disability
Mental health conditionNo LTC (for carers only)Other
Physical disabilitySensory impairmentStroke
Unexplained medical symptoms

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

AbuseAlcohol / substance misuseAnimals
Criminal ConvictionFalls/unsteady/mobility Language barrier
Mental health related OtherSensory impairment (including sight/hearing)
Violence

Social Prescribing Goals. Please provide additional details on the goals the client wishes to achieve

Referral Information *

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

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 you 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 may be shared with the patient’s GP.

We recognise that this form asks for some sensitive information.The fields marked * are necessary in order for us to deal with your enquiry appropriately.

You have rights regarding your personal data, including seeing what data is held, and to make sure it’s accurate and up to date.Your 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: lvet.co.uk.

If you understand and agree to this please select Yes below.

YesNo

Subject*