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 Community Connectors Slough CVS by Community Connectors - Slough 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 "Lives in Slough" 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 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? Loneliness/isolation Employment Food Poverty Mental health Transport Housing problem Bereavement Physical exercise Practical household support Anxiety or Low Mood Paperwork & Form Filling Debt and Welfare support Homelessness None of the above (please specify below) 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: This field is required. Please share some brief details regarding this referral Risks (if any) Self-harm Suicide Verbally aggressive Self neglect Violent Victim of domestic abuse Not known This field is required. Can the client communicate via telephone? Yes No This field is required. Preferred language (we cannot provide interpretation services) Is Next of Kin primary contact? Yes No This field is required. Next of Kin contact details (please provide name and telephone number) Where are you referring from? SelectAdult Social Care - North / South Locality Adult Social Care - Hospital Social Work Team Adult Social Care - East Locality Adult Social Care - CTPLD Adult Social Care - OT / Reablement Health - Iris Health - Ward visits Health - A&E Health - NHS teams (e.g. LAP, Physios, Community Matrons) Health - CMHT Community Referral - Community Organisation Community Referral - Self Referral Other Referral - (e.g. Debt and Welfare Team, DWP, SBC contact centre) 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
