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:
Please select...
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)
Health Professional
Social Care Professional
Charity
Event or briefing
Leaflet / Poster
Social Media (e.g. Facebook, Twitter)
Internet Search / Website
Newspaper / Magazine
Television / Radio
Other
Other
Do you give your consent for Independent Age to hold your information?
Yes
No
Have you gained consent of the individual(s) you are referring to share their information with Independent Age?
Yes
No
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
Title
Please select...
No Title
Councillor
Dr
Lady
Lord
Miss
Mr
Mrs
Ms
Prof
Rev
Sir
Sister
First Name
Last Name
Phone Number
Email Address
Organisation Nam
e
(if applicable)
Your Sector
Family or Friend
GP Surgery
Hospital
Other Health Organisation (e.g. dentist, optician, pharmacy)
Social Care Team
Other Council Team
Housing Association
Private Care Provider
Voluntary or Community Sector
Emergency Services
Other
Other Sector (please specify)
Your Job
Family or Friend
GP
Nurse or Community Matron
Social Prescriber
Doctor (non-GP)
Pharmacist
Therapist (e.g. OT, PT etc)
Other health practitioner
Social Worker
Carer or Personal Assistant
Support Officer
Local Area Coordinator/Navigator
Voluntary or Community Sector Employee/Volunteer
Paramedic
Fire Marshall
Police Officer
Other
Other Job (please specify)
Participant Details
Title
Please select...
No Title
Councillor
Dr
Lady
Lord
Miss
Mr
Mrs
Ms
Prof
Rev
Sir
Sister
First Name
Last Name
Email
Preferred Name
Date of Birth
Telephone Number
NHS Number
(if known)
Participant Address
Address Line 1
City
County
Postcode
Reasons for referral to Reconnections
(please give as much information as possible relevant to circumstances and any feelings of loneliness)
Risk factors
(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?
Yes
No
Full Name
Email and/or Telephone
Address
Relationship to the individual
Our Privacy Policy