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 - East Staffs by East Staffs PCN I am signing up myself I am referring someone else Service access criteria Tick to confirm you have checked the service access criteria 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 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 High body weight Finances Caring responsibilities Loneliness/isolation Employment Food Poverty Covid/Long Covid Mental health Substance misuse Transport Legal advice Managing a long-term health condition Day-to-day helping hand Victim of abuse Housing problem Bereavement Holistic Lifestyle 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 Does this patient have any patient warnings? SelectNo Yes If yes to patient warnings, please provide details. If no, please answer n/a Please list any other professionals/ services who are currently supporting this patient *Please state the barriers that prevent the patient from addressing their issues themselves ( at least one must apply): Anxiety Lack of confidence Poverty Poor digital literacy Learning Disability Learning Difficulty Memory loss Low Mood Hearing Loss Sight loss Housebound Lack of transport Other: This field is required. *Please state the objective that the patient wishes to address / achieve through the support of Social Prescribing: If referring for cancer rehabilitation support ( Holistic Lifestyles Programme), please confirm whether the patient is pre-treatment or post-treatment Pre-treatment Post-treatment Spoken language. Please state if an interpreter is required. If referring for BACT Better Pain Managment Support group please state patient's surgery Peel Croft Stapenhill 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
