Refer to Good Neighbours

Referring an older person to Good Neighbours couldn’t be easier. Just complete the Referral Form below to get started, or alternatively download the full referral form.

Please make sure you have discussed the referral with the person you are referring.

Name of referrer *

First

Last

The person I am referring has consented to this referral & is aware of it. *

• Yes, they have given consent.

Please seek consent before completing this referral form.

Referrer organisation

If you are referring on behalf of an organisation, please let us know which one.

Referrer email *

Name of client *

First

Last

Client address *

Client postcode *

Client phone number(s) *

Client email address (if applicable)

Client date of birth *

Complexities about client

• Dementia
• Learning disability
• Mental health issues
• Poor mobility
• Visual impairment / Illiterate
• Hearing impairment
• Domestic abuse
• Alcoholism / Drug addiction
• Criminal history
• Other (e.g. bereavement, personality)

Please select all that apply.

If you selected a complexity above, you must provide more details

Primary language spoken (if not English)

Client's home circumstances *

Apart from loneliness, is there any other relevant information about the client?

Client's emergency contact *

First

Last

Emergency contact phone number *

What relationship is the emergency contact to the client? *

Client's GP surgery name *

Are any other organisations currently supporting the client?

Are you referring the client to any other organisations?

What would the client like the referral for? *

• Home befriending
• Telephone befriending
• Postal befriending
• Group clubs and activities
• Other help (please specify)

Select all that apply

If you selected 'Other help', please provide further details.

Please note that our volunteer befrienders cannot provide any personal care, respite care or go shopping for a client.

Is a 2 person visit required (for safety)? *

• Yes
• No
• Unsure

GDPR agreement *

• I consent to having Good Neighbours store the submitted information so that they can process my referral.

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