Community Navigator referral form

Refer someone to a Community Navigator, who can help them access community services to maintain their independence, health and wellbeing.

Contact details
Referrer's details
Referrer's name

First name

Last name
Referrer's organisation
Contact phone number
Email
Date of referral (dd/mm/yyyy)
I confirm that I have obtained verbal consent from the client/ patient for the Community Navigator to make contact with them.
I want to receive feedback on the outcome of this referral.
Client details
Client's title (e.g. Mr. Ms. Mrs)
Client's name

First name

Last name
Client's address line 1
Client's address line 2
County
Postcode
Client phone number
Client's GP and GP surgery
Client's NHS number
Client's date of birth (dd/mm/yyyy)
Client's ethnicity

Please let us know anything that you feel would be helpful for the Community Navigator to know before they make contact with the client. Please also include any known risks of safeguarding issues.
What would you like the Community Navigator to contact the client about? Tick all that apply:
How to have a healthy lifestyle and stay physically fitEmotional support and someone to talk toAdvice about money or benefitsGroups and activities to join to prevent isolationHelp to feel safe at homeHelp to keep warm or stay cool at homeHelp to stay independentSupport for a carer (i.e. carer breaks etc.)Support with children's issuesHelp to explain a problem or for them to have their sayOther (see below)
If you'd like support for any other issues, please specify:

Hertfordshire County Council – The County of Opportunity