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Social Prescribing Self Referral Form

This service is for people who are a registered patient with a GP Surgery in Pershore and Upton, The Vale of Evesham and Wyre Forest Network of Independent Practices. Social Prescribers offer support with non-medical support recognising that your health is determined by a range of social, economic and environmental factors such as poor wellbeing, financial issues, loneliness, grief, and so much more.

Please complete all mandatory fields or your referral will not be processed.

If you are completing this form on behalf of someone else, do you have consent from them to make this referral? If there is no consent, please do not continue with this referral form as you will be breaching GDPR by sharing patient information.

Are you referring yourself or completing the form for someone else?

Myself

Someone Else

First name

Last name

Date of birth

Address

Method of contact

Email

Phone number

GP Details

Demographics

Is there any further information you can detail about why support is needed?

Is there any further information in terms of health, risks or other accessibility issues it is important to make us aware of?

Data Protection, Information Sharing

What information do you hold about me? For us to provide you with a service we need to record some of your personal information. This can include: your name, address, telephone numbers, date of birth, email address, ethnicity, or any vulnerabilities.

I consent to ONSIDE storing and using the personal information I have provided and understand how ONSIDE will use personal data and my rights:

Consent

Yes

What we do with your information and who we share it with: This information remains confidential and will only be shared with those directly involved in your support.We may also use general statistical information about you that has been anonymisedin order to report back to the Department of Health and Social Care and for internal monitoring purposes.We will not disclose your information to any other third parties without yourpermission unless there is a legal requirement to share the information, or there is a safeguarding concern for which we are required by law to share information with the relevant Local Authority (this can be without your consent), however, we will always endeavour to inform you beforehand.Your rights:You have the following rights under data protection legislation:To know what information ONSIDE holds about you ('right to be informed') To request access to or a copy of the information ONSIDE holds about you ('rightof access') To have your data corrected if it is inaccurate ('right to rectification') To have your data erased where ONSIDE does not have an overriding legal obligation orreason to retain it ('right to erasure') To prevent your data being used, if you have contested and are pending resolutionin relation to its lawful use, accuracy, or impact of your rights, or require that it is retained in relation to a legal claim (‘right to restriction of processing’) To object to its use, including opting out of receiving marketing such as our newsletter(‘right to object’) To request that we pass data about yourself, that you provided us, to anotherorganisation on your behalf (‘right to data portability’) How long we hold your information and how you can access it:Your information will be held securely for 7 years as required by contract, afterwhich, it will be safely destroyed.During this time, you have the right to request a copy, of any personal information wehold about you. Should you wish to do this please ask our administration team for further information.Onside ensures that they will comply with all legislation relating to the collection and retention of data including but not limited to the Data Protection Act 1998.Our guiding principle is that we are holding your records in strictest confidence.You may withdraw your consent at any time, for further information please contact our administration.As part of this project, ONSIDE may support you into other services. This may be access to further mental health support,housing support or access to counselling. If you do not want us to share information with external organisation, please let your worker know who will update our records.