Linkage Plus Referral form

First name of person being referred to LinkAge Plus

Last name of person being referred to Linkage Plus

Contact phone number or email of person being referred to LinkAge Plus

Postcode of person being referred to LinkAge Plus

Date of birth of person being referred to LinkAge Plus

How can LinkAge Plus support this individual?

Does the person you are referring need translation support? If yes, please state which language

Urgency
HighMediumLow

Please note that LinkAge Plus is not an Advice Service. If the person you are referring requires assistance from Adult Social Care please contact Tower Hamlets Connects directly enquiry@towerhamletsconnect.org or 0300 303 6070 (weekdays 9am to 5pm)

Consent - By completing this form you confirm that you have spoken to the person you are referring and gained their consent for us to contact them.

Please enter your name

Please enter your email or contact number

Data Protection – We will only use the information provided to contact the person you have referred to us in regards to LinkAge Plus, or to contact you if we are unable to contact the person.