Tel: 01322 524 682
Email: communityconnect.bvsc@nhs.net

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Your Details (*Mandatory fields)

If you would like to find your NHS number follow this link
Client Contact Preferences
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If this client/ Patient has a carer, then please add details below

Reason for Referral *

Long Term Conditions

If you wish to add a Long Term Condition not listed, you can add one using the free text option below.
Long Term Condition (Free Text)

Risk Factors

Referral Information *

Please provide additional details on the context of this referral, including any concerns or comments that may help us support you.

Data Sharing Statement

Community Connect aims to connect you with local services which may be able to provide you with information, advice and support. In order to refer you to these services, it is necessary or helpful for us to share information with relevant organisations. We will also provide statistical data on the outcomes of our service to the funders of this service, although that information will be anonymised so you will not be identified.

We recognise that this form asks for sensitive information. You can opt not to share your data, but we will not be able to process your referral if you choose this option. You have the right to get a copy of information held about you under the Data Protection Act however there are exemptions. If you’re worried about sharing your information, or would like to see a copy of information that is held about you, please contact Community Connect on 01322 524 682 opt 1.

If you understand and agree to share your information please tick below.