CONNECT FOR HEALTH - Self Referral Form (Access Community Trust)

SOCIAL PRESCRIBING: A new way of working with YOU

We know that taking care of your health involves more than just medicine. With Connect for Health you can get specialist support for more than medical issues.

Your local Community Connector will arrange an appointment to spend time with you exploring what activities and/ or local support could improve your health and wellbeing.

The details you provide us with remain are securely stored so that we can work with you and your GP surgery to provide you with the best solutions.

You can alternatively email connectforhealth1@accessct.org if you wish.

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* 1. Your contact details:

Name

Address

Address 2

Town

County

Postcode

Email Address

Phone Number

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* 2. Your Date of Birth:

Please confirm your birth date

Date

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* 3. Your Gender:

Male

Female

Other

Rather not say

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* 4. Preferred contact menthod:

Telephone (Call)

Telephone (Text Message)

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* 5. GP Surgery Name:

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* 6. Name of your GP

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* 7. Referral reason: (The below are some of the number of things we can help you with)

Weight Management

Physical Activity Support

Healthy Eat

Smoking/Drug/Alcohol/Other Addictive Behaviours

Anxiety/Stress/Depression/Low Mood

Social Isolation

Learning/Training/Employment

Money/Debt/Benefits

Housing Issues

Bereavement

Carer

Other (please specify)

Once you click the send button below, your details will be securely passed to one of our Community Connectors. They will then contact you via your preferred contact method.