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 - Colne Union PCN. WAITING LIST IN ACTION! by Hillingdon - Colne Union 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 "Non-medical and not an emergency or urgent service! For 18+ without complex mental health needs. Unable to accept referrals for patients who are currently under the care of the CCT, HIU or the Wellbeing Support Officers / Advisors." Your Details First name Last name 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 Do not enter protected health information (PHI) or any other personal data in these fields. What are the reasons for this referral? Sedentary lifestyle Finances Caring responsibilities Loneliness/isolation Employment Food Poverty Substance misuse Transport Legal advice Day-to-day helping hand Bereavement Stress Training and Education Crown Lodge Accommodation Novotel 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 do not write "see consultation notes". Please provide a clear and detailed reason for the referral. This will help us ensure that social prescribing is an appropriate service for the patient Is the patient already being supported by any of the below services? CMHT H4ALL ARCH Adult Social Care – Patient has a Social Worker CCT – If the pt is under the CCT please do NOT refer to Social Prescribing and speak to the CCT WSA. Patient is not under any other services Other: This field is required. Which GP Practice are you registered with? High Street Practice Yiewsley Family Practice The Medical Centre - The Green Otterfield Medical Centre Oakland Medical Centre This field is required. Patients Current and Historic Background Mental Health History Safeguarding History Forensic History None Please provide details of the concern, actions taken and support in place to manage the mental health, safeguarding and or forensic history. Patients preferred language I understand that Social Prescribing Service is a non urgent, non-medical, signposting and referral service. That will provide me details of services that I can access to support my social / practical / well-being needs Please confirm that the patient is over 18 years old I understand that there is a waiting list and the team will aim to make contact within 4 weeks. 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
