Making Connections Referral Form
Referrals are accepted for people over 65 in Dublin South. FORM CONTENT: P1: Supports & Client Profile | P2: Client Details | P3: Referring Agent Details
Support Selection
Which support is required:
*
Regular visits for social interaction at home/ café (befriending)
Buddy support to link with community activities (club/ class/ event, etc)
Telephone befriending calls
Walking companion
Walk and Talk Group (Churchtown, Wednesdays 11:00 - 12:30)
Assistance to use digital devices/ access information
Other Supports - please specify or call us to discuss
Client Profile
Why is the support of Making Connections needed?
*
LIVING SITUATION - tick all that apply:
*
Lives alone
Lives with Spouse/ Partner
Lives with Family
Other
PRACTICAL SUPPORTS - tick all that apply:
*
Yes
No
Home Support
Day Centre
Meal Supply
Visits from Family
Visits from Friends/ Neighbours
If any of these supports are in place - give details (days/ times)
*
COMMUNICATION CHALLENGES: Do any of the following apply?
*
Yes
No
Visual Impairement
Hearing Impairment
Speech Impairment
Cognitive Impairement
If yes, please give details
INFORMATION RELEVANT TO HOME VISITS & VOLUNTEER SUPPORT:
*
Client is a smoker
Client has a pet
Other
Client's previous occupation
*
Client's interests/ hobbies
*
Any specific RISK concerns?
*
MOBILITY STATUS
*
Yes
No
Client can mobilise independently +/- walking aid
Client does NOT require physical assistance to mobilise
Client can mobilise outdoors > 15mins
Mobility Aid Used
*
Nil
Walking Stick
Crutches
3 Wheel Rollator
4 Wheel Rollator
COGNITION STATUS:
*
Yes*
No
Does the client have cognitive impairement?
*If 'Yes' Please provide formal cognitive test score if known (e.g. MOCA/ MMSE)?
*If 'Yes' Please provide details of nominated person to accompany them on the walk
First Name
Last Name
*If 'Yes' Nominated Person - Relationship to client:
*If 'Yes' Nominated Person - Phone:
*If 'Yes' Nominated Person - Email
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Client Personal Details
1.1 Client Name
*
First Name
Last Name
1.2 Client D.O.B.
*
-
Day
-
Month
Year
Date
1.3 Client Phone number(s)
*
1.4 Client Email Address (where relevant)
example@example.com
1.5 Client Address
*
Address line 1
Address line 2
Area
County
Eircode
1.6 GP Name + Practice
*
1.7 Client's PHN (if known)
Alternative Contact Person
Next of Kin or other emergency contact
2.1 Name
*
First Name
Last Name
2.2 Relationship to Client
*
2.3 Location (County/ Country)
*
2.4 Phone Number(s)
*
2.5 Email Address
example@example.com
Consent 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 Making Connections and understands that information may be shared with relevant HSE Staff as required.
*
Yes
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Final Section - Referral Agent Details
3.1 Name
*
First Name
Last Name
3.2 Occupation
*
Please Select
PHN
Occupational Therapist
Physiotherapist
Social Worker
Other
3.3 Primary Care Team (if n.a. indicate client's PCT where relevant)
*
3.4 Phone Number(s)
*
3.5 Email
*
example@example.com
Any additional comments/ information (optional)
*
I consent to my data being stored in accordanceto the Making Connections GDPR Policy.
Submit
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