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If you don't have all the information we ask for, just leave it blank or select Unknown.

Befriending Service provides befrienders to alleviate isolation for people who are experiencing isolation and loneliness. The service is appropriate for people:

Over 60 years old

Referrals must be appropriate for VOLUNTEERS who might/will be visiting alone in the person’s home. Alternatively, we may choose to provide telephone befriending services or group befriending services, if deemed to be more appropriate, or a combination of the two.

Is the person:

Known to be aggressive or violent?
Known to have a severe memory/cognitive impairment or severe dementia?
Known to have an Autistic Spectrum Condition diagnosis or other Learning Disability?
Unable to engage in verbal communication?
Living with severe anxiety or experiencing suicidal thoughts?
Supported by another befriending agency?

If the answer is 'YES' to any of the above questions it suggests that we need to have a more detailed conversation with you prior to taking on the client into our services.

Please contact the Befriending service on 01638 608 048 to discuss next steps.

Yes

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Please enter the personal details of the person you are referring into our service

First name *

Last name *

Enter the postcode to search for the address

Address line 1 *

Address line 2

Town/City *

Postcode *

County

Country *

Please fill out at least one contact number.

Phone number

Can we leave a message? *

Yes

Email Address

Date of Birth*

If you don’t know their DOB, please enter today’s date

Identified gender *

Ethnicity *

Does the person being referred need an interpreter? *

Yes

Languages spoken

Are you happy for us to connect you with partner organisations who provide interpreting services?

Yes

Emergency Contact Name *

Emergency Contact Phone Number *

Details of the person making the referral

If you are self-referring, please enter your own details here.
If you are referring someone else, please provide your contact details.

I'm referring myself

Yes

Referral details

These are the details regarding the referral.

Has the client given explicit permission for us to contact them?

Yes

Since no permission has been granted we cannot act further

Please obtain the client's permission and re-submit the form.

What support would they like from our service?

Are there any preferences for a befriender?

Please also let us know if the person has refused befriending support in the past for any reason, and if yes give reasons? *

Yes

Reason *

Please write a brief description of the reason for this referral.
If the person gets support from other services, please let us know which services.

Interests

These are details about the person referred interests.

Hobbies

Any further information about hobbies and interests that we can use to match the client with a befriender.

Is the individual interested in finding more ways to stay in touch with people socially (including online)? *

Yes

Relevant health history

These are details about the person being referred.
If you do not know this information, please press next to skip this section.

Do they have any existing health conditions?

Yes

Choose existing health condition (you can select more than one)

Do they have a disability?

Yes

Choose disability (you can select more than one)

Do they have any other accessibility, communication or support needs?

Are they currently receiving support from any Mental Health professional?

Yes

If so, give details of name email and telephone number

Additional Factors

These are details about the person being referred.

Smoker?

Yes

Any pets?

Yes

Can you tell us more about the pets?

Please tell us more about the known allergies?

What best describes their household type?

How often do they see or speak to friends, family or neighbours?

Does the person have any unspent criminal convictions or cautions? If yes please give details *

Yes

Details

Please give any further information regarding any concerns that you think it would be useful for us to know.

GP Surgery/Care agency details

These are details about the person being referred.

Select GP surgery

Who is their GP? (if known)

What's their NHS Number? (if known)

Are they receiving care or support, and if so, from which agency?

Thank you for successfully submitting this form to the Befriending Network.

If you need to talk to anyone about your referral, please contact befriending@thevoluntarynetwork.org or call us on 01638 608 048.

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Befriending Referral Form