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 Social Prescribing - Meir PCN by Meir PCN - Wellbeing Team I am signing up myself I am referring someone else Service access criteria Tick to confirm you have checked the service access criteria "18+, Not in a care home/palliative care / terminally ill, No severe/complex and enduring mental health problems in crisis and in need of secondary mental health support, Not in severe crisis, Unable to support where the need is clinical - medications/controlling their conditions" Your Details First name Last name Known as Date of birth Email Don't know / client doesn't have an email address Email is invalid We already have an account with this email. Please log in. Password Reset my password Log in 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 What are the reasons for this referral? Sedentary lifestyle Finances Caring responsibilities Loneliness/isolation Employment Food Poverty Mental health Substance misuse Transport Day-to-day helping hand Housing problem Bereavement Physical Health Social Networks Mental Wellbeing Employment/Volunteering Long Term Condition Support Housing Issues Support with discharge from hospital to home Bereavement counselling Education to manage long term conditions Support for homelessness and outreach Physical/Learning Disability Money Management/Debt/Benefits Peer Support Arts and Crafts Smoking Cessation 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 Consent to messages being left? Yes No Consent to talk to others if not to the patient? Yes No Please outline any known risks to staff from patient/family/ carers which will require a joint visit, it is important that staff are aware and can act appropriately to any risks Please outline medical history in as much detail as is relevant (e.g. health condition/mental health difficulty) Please outline what support is needed Confirmation and consent Tick to confirm you consent to share this information with the service provider and Joy Tick to confirm you consent to the service provider contacting you directly 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
