Referral Form
Referrals are accepted for people over 65 in Dublin South
Referral Agent Details
1.1 Name
*
First Name
Last Name
1.2 Occupation
*
Please Select
PHN
Social Worker
Occupational Tehrapist
Other
1.3 Phone Number(s)
*
1.4 Email
*
example@example.com
*
I consent to my data being stored in accordanceto the Making Connections GDPR Policy.
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Client Contact Details
2.1 Client Name
*
First Name
Last Name
2.2 Client D.O.B.
*
-
Day
-
Month
Year
Date
2.3 Client Phone number(s)
*
2.4 Client Address
*
Address line 1
Address line 2
Area
County
Eircode
2.4 Client's PHN (if known)
Alternative Contact Person
Next of Kin or other suitable contact
3.1 Name
*
First Name
Last Name
3.2 Relationship to Client
*
3.3 Location (County/ Country)
*
3.4 Phone Number(s)
*
3.5 Email Address
*
example@example.com
Constent for Referral
Who has provided consent for this referral?
*
Client
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
*
Yes
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Support Selection
Select the supports(s) required
*
Befriending Visits & Wellbeing Supports
Community Meals
Other
Why is the support of Making Connections needed?
*
Befriending & Supports Information
Does the client have any of the following in place?
*
Home Supports
Day Care
Meal Suppoly
Family Visits
Friends/ Neighbours Visits
N.A. (no supports or visits)
Other
If any of these supports are in place - give details (days/ times)
*
Does the client have difficulties with any of the following?
*
Speech
Hearing
Vision
Mobility
Cognitive Status
N.A. (no diffiulties with the above)
Other
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?
*
Yes
No
Final Section
Any other comments/ information
*
Submit
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