Camden Care Navigation & Social Prescribing Service
Referral Form

Referral Date: 
	
RESIDENT DETAILS
Name: Title Given Name Surname 	DOB: Date of Birth 	Age: Age 	
Gender: Gender 
Address: Home Full Address (single line) 
Home tel: Resident telephone	Mobile: Resident mobile phone	
Email: Resident Email
Ethnicity: X
NHS No.: X
Has at least one long-term condition (LTC)?: Y/N
	
REFERRER DETAILS
Referring organisation:   Organisation name      
Referrers Name: Current User 
Address: Organisation Full Address (single line) 
Contact: Organisation Telephone Number      Email: Organisation E-mail Address 
	
GP DETAILS (if different from referrer details)

Surgery Name:   Organisation or practice name      
GP’s Name: GP Name 
Address: GP Full Address (single line) 
Contact: GP Telephone Number      Email: GP E-mail Address 
	
Data Protection Consent Statement (To be read to the resident if present)
In completing this form or having this form completed on your behalf you are consenting to your information being shared with i) the organisations you have asked to be put in touch with, so they can contact you ii) Camden Community Links, who administer this scheme, iii) Wish Plus (Camden Council) who are part of this scheme and iv) Age UK Camden for monitoring and evaluation purposes.

Please note: Age UK Camden runs a triaging scheme for housing-related queries, to refer you on to other organisations that can best meet your needs. In completing this form for housing-related queries, you consent for your information to be shared with these third parties to make such onwards referrals.

You can withdraw your consent at any time. This is in accordance with the General Data Protection Regulation 2018.

Please note: Community Links, Community Connectors and Wish Plus have no access to residents’ medical records.

Has the referred person given consent for this referral?  Yes   No 
	
DESTINATION SERVICE

Care Navigator   Social Prescribing Link Worker  Community Links    
WISH+     		For Triage    

Have you already referred this person to any other Social Prescribing service in Camden e.g. Mental health social prescribing?  Yes  No   If yes, which service? 

Free Text Prompt 
	
REASON FOR REFERRAL

Free Text Prompt 
	
INFORMATION TO SUPPORT REFERRAL

Are there any identified risks (to self or others) that we should be aware of?

Free Text Prompt 
	
CONTACT PREFERENCE
Please tick if it is ok to contact you via -   
 Telephone (inc Text)     
 Email  
 Letter 
 Face to Face  

https://www.ageuk.org.uk/camden/privacy-policy/