Community Navigator Professional Referral Form - East Cambridgeshire

This forms is intended for professionals to fill on behalf of people who require support. If you are a member of the public looking for Navigator support, please phone or email us directly using the details on our website. The Community Navigator service supports adults to identify and work towards beneficial outcomes. We can signpost to, and provide information and guidance on services in the local area. By completing this form you confirm that you have had an initial discussion with the individual about the Community Navigators service, and you both have agreed consent to the sharing, use and storage of this information by Care Network. Please complete this form as fully as possible to enable us to provide the best possible support. Prefer a conversation with a human? Feel free to call us ahead of completing your referral.

Details of person being referred (*indicates mandatory field)

Name: *

Address: *

Phone/s: *

Email: *

Date of birth: *

NHS Number: *

Name of GP Practice: *

Preferred contact method/date/time: *

Background: Please tell us why you are referring this person? * *

What do they hope to achieve? *

Is your (or any other) organisation delivering support? *

Is there any support or involvement by the client’s family? *

Are any of the following preventing this person from connecting with their community? *

Further information if available:

Risk/ Concerns

A Community Navigator or Volunteer may carry out a home visit. Are you aware of any risks associated with this person, or within their home? Please list *

Please provide further information about how these risks have been identified: *

Referrer details (person who we can update about this referral)

Name: *

Role: *

Organisation: *

Phone: *

Email: *

Primary contact (where different from the person being referred):

Name:

Relationship to person being referred:

Phone:

Email: