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 Thrive Social Prescribing for Young People 1:1 Support by Young People Social Prescribing 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 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? Seeking to develop independence skills Experiencing social anxiety Experiencing low mood Experiencing loneliness and social isolation Seeking support to make positive change Experiencing anxiety around school Other: This field is required. Please share some brief details regarding this referral Which GP surgery does the patient belong to? SelectBarlborough Medical Practice Blackwell Medical Centre Castle Street Medical Centre (DCHS partnership) Crags Healthcare, Whitwell Health Centre Creswell & Langwith (DCHS NHS Foundation Trust) Emmett Carr Surgery Friendly Family Surgery Killamarsh Medical Practice Shires Healthcare Springs Health Centre The Valleys Medical Partnership Welbeck Road Surgery Royal Primary Care Grangewood RPC Inkersall RPC Staveley RPC Ashgate RPC Holme Hall RPC Whittington Not Applicable - other referral criteria Royal Primary Care Inkersall Royal Primary Care Staveley Royal Primary Care Ashgate Royal Primary Care Holme Hall Royal Primary Care Whittington Not Applicable - other referral criteria Royal Primary Care Inkersall Royal Primary Care Staveley Royal Primary Care Ashgate Royal Primary Care Holme Hall Royal Primary Care Whittington Not Applicable - other referral criteria Young Person's Preferred Pronouns Does the young person have any diagnosed medical condition/s we should be aware of? Has the young person had CAMHS involvement in the last 12 months? If yes, please give details below Yes No This field is required. Does/Has the Young Person have contact with any other agencies or support? Please provide details where possible including name of workers if known. Next of Kin Name Next of Kin Relationship to Young Person: Next of Kin Address (if different) Next of Kin Contact Number Name of School/College (if applicable) Key Staff Involved (if applicable) Staff/School Contact Details (if applicable) To engage with Thr1ve social prescribing service, the Young Person is: (please select one of the following) Selectregistered at North Hardwick and Bolsover PCN registered at North Derbyshire PCN (Royal Primary Care)) a resident of Glossop a resident of Chesterfield Borough Council a resident of North-East Derbyshire District Council a resident of Bolsover District Council a resident of Amber Valley District Council a resident of North Derbyshire Dales The Young Person has agreed to engage with Thr1ve Social Prescribing Service Yes, the Young Person has agreed to engage with the service This field is required. How does the young person prefer to be contacted? Phone Email Text Which GP surgery does the patient belong to? (*PLEASE NOTE WE DO NOT HAVE ACCESS TO SYSTMONE*) SelectCastle Street Medical Centre (DCHS partnership) Crags Healthcare, Whitwell Health Centre Creswell & Langwith (DCHS NHS Foundation Trust) Emmett Carr Surgery Friendly Family Surgery Shires Healthcare Welbeck Road Surgery Royal Primary Care Grangewood Royal Primary Care Inkersall Royal Primary Care Staveley Royal Primary Care Ashgate Royal Primary Care Holme Hall Royal Primary Care Whittington Other Referral Criteria 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
