Referrals are accepted for people over 65 in Dublin South
Referral Agent Details
1.3 Primary Care Centre
1.4 Phone Number(s)
I consent to my data being stored in accordanceto the Making Connections GDPR Policy.
Client Contact Details
2.1 Client Name
2.2 Client D.O.B.
2.3 Client Phone number(s)
2.4 Client Address
Address line 1
Address line 2
2.4 Client's PHN (if known)
Alternative Contact Person
Next of Kin or other suitable contact
3.2 Relationship to Client
3.3 Location (County/ Country)
3.4 Phone Number(s)
3.5 Email Address
Constent for Referral
Who has provided consent for this referral?
NOK/ Alternative Contact
I confirm that I have discussed the referral with the client/ nok and confirm that the Client has given informed consent to be referred to MakingConnections
Select the supports(s) required
Regular visits for social interaction at home/ café (befriending)
Buddy support to attend community activities (club/ class/ event, etc)
Telephone befriending calls
Walk and Talk Groups
Assistance to use digital devices/ access information
Other Supports - please specify or call us to discuss
Why is the support of Making Connections needed?
Further Information Required
Does the client have any of the following in place?
Friends/ Neighbours Visits
N.A. (no supports or visits)
If any of these supports are in place - give details (days/ times)
Does the client have difficulties with any of the following?
N.A. (no diffiulties with the above)
If yes, please give deatils
Do any of the following apply?
Client lives alone
Client has a spouse
Client has children
Client has pets
Client is a smoker
N.A. (none apply)
Any specific RISK concerns?
Client's previous occupation
Client's interests/ hobbies
Community Meals Information
"Good Food Delivered"
List any known food allergens
Any potential barriers to receiving meals/ billing? (e.g. mobility/ speech/ hearing/ cognition, etc)
Additional Community Meals Consent
The Client/ NOK has consented to informaotin being hsraed with the HSE for billing purposes
The Client/ NOK has consented to be contacted by Airfield for Client Contribution billing puposes
Airfield Estate conducts research about food. Does the client consent tobe contacted by Airfield about participating in research on the topic of foodfor older people?
Any other comments/ information
Should be Empty: