This referral has NOT been sent yet. You will be redirected to the listing's external referral form. Please complete the referral form there to submit the referral confirm Details Pendle East Neighbourhood Team by Pendle East PCN Who is this referral for? I am signing up myself I am referring someone else Service access criteria Tick to confirm you have checked the service access criteria "To refer into this service, you must be registered with one of the 5 Pendle East GP surgeries, these are The Richmond Hill Practice, The Pendle Medical Practice, Harambee Surgery, Barrowford Surgery and Barnoldswick Medical." Your Details Email Email is invalid We already have an account with this email. Please log in. Password Reset my password Log in First name Last name Your relationship to the person Organisation name Who are you referring? First name Last name Known as Date of birth Email Don't know / client doesn't have an email address Phone Address Line 1 Address Line 2 Town/City Postcode GP surgery NHS number Ethnicity SelectEnglish, Welsh, Scottish, Northern Irish or British Irish Gypsy or Irish Traveller Any other White backgroundWhite and Black Caribbean White and Black African White and Asian Any other Mixed or Multiple ethnic backgroundIndian Pakistani Bangladeshi Chinese Any other Asian backgroundAfrican Caribbean Any other Black, African or Caribbean backgroundArab Any other ethnic groupPrefer not to say Gender SelectFemale Male Transgender female Transgender male Non-binary Intersex Not specified Not known Other Additional referral details Do not enter protected health information (PHI) or any other personal data in these fields. What are the reasons for this referral? Social Isolation Depression/ Anxiety Volunteering Mental Health Issues Self-esteem/ confidence Physical activity Training Education Financial Issues Housing Nutrition Other: This field is required. Should the service provider be aware of any additional needs? Blind/partially blind Memory problem Hearing loss Housebound Does not speak English Poor mobility Learning and communication needs Physical disability Frail Other: Please share some brief details regarding this referral Please make sure your brief details above include history, current problems and patient expectations of what the patient would like support with — please confirm this has been included. Additional Needs and Considerations (please select all that apply): The person being referred is a veteran or currently serving Armed Forces member There are known risks associated with the client The patient already has input from other community services The patient is considered vulnerable There is a known safeguarding alert in place It is not safe for a staff member to visit alone The patient is happy for their records to be shared with other organisations within the neighbourhood team This field is required. If you have selected any of the above options, please provide further details here: Confirmation (Not for INT): I confirm this referral is not for INT. If it is, please submit via EMIS and email to elht.pendleeastint@nhs.net MHWP Self-Referral Check: I confirm this is not a self-referral into the MHWP service. Which team are you directing this referral to: Social Prescribing Team – James Smith / Pam Bayliff MHWP – Natasha Darcy Health & Wellbeing Coach – Ady Lamb Andrew McCrimmon John Verity Has the patient been identified through a practice assessment? If yes, please specify: Confirmation and consent Tick to confirm you have gained consent to share this information with the service provider, your organisation and Joy Tick to confirm the service provider can directly contact the client Would you like to create an account? Make referrals faster next time you use Joy. Registered users can message service providers, submit reviews and track the progress of their referrals online. Password Weak password! Use at least 8 characters Use upper and lowercase characters (a-z) Use 1 or more numbers (0-9) Confirm password Please enter the same value again. required Submit Email: Password: Email
