Reconnections Referral Form
Thank you for your interest in accessing the Reconnections service. Please complete our referral form below and we look forward to speaking to you soon.
Please select the area you are in:
Barking & Dagenham and Havering
Guildford and Waverley
Are you referring yourself or someone else whom you know to Reconnections?
I would like to refer myself
I would like to refer someone else I know
Where did you hear about Reconnections?
Word of Mouth (e.g. family, friends)
Social Care Professional
Event or briefing
Leaflet / Poster
Social Media (e.g. Facebook, Twitter)
Internet Search / Website
Newspaper / Magazine
Television / Radio
Do you give your consent for Independent Age to hold your information?
Have you gained consent of the individual(s) you are referring to share their information with Independent Age?
Please gain the permission of the person you would like to refer before continuing the referral process.
Without consent to hold your information we will not process this referral and pressing Submit will do nothing.
Referrer Contact Details
Family or Friend
Other Health Organisation (e.g. dentist, optician, pharmacy)
Social Care Team
Other Council Team
Private Care Provider
Voluntary or Community Sector
Other Sector (please specify)
Family or Friend
Nurse or Community Matron
Therapist (e.g. OT, PT etc)
Other health practitioner
Carer or Personal Assistant
Local Area Coordinator/Navigator
Voluntary or Community Sector Employee/Volunteer
Other Job (please specify)
Date of Birth
Address Line 1
Reasons for referral to Reconnections
(please give as much information as possible relevant to circumstances and any feelings of loneliness)
(please give any information that we should be aware of ahead of meeting with the person you are referring)
Alternative Contact Details
Please only complete if this person will be the main contact for making appointments
Has the alternative contact consented to Reconnections holding their details?
Email and/or Telephone
Relationship to the individual