Client self-referral form

About Buddies for All
Buddies for All is a social and leisure buddying scheme that supports disabled people with all social and leisure activities in London. We support people with physical, sensory and hidden disabilities, such as chronic illnesses or neurological conditions, currently aged 18-65. However, as our organisation develops, it is our aim to provide a buddy to as many disabled people as possible, at our discretion based on the capabilities of our volunteers.

You can have a buddy if:

You are a disabled person
You want a buddy for a social or leisure activity
You are aged 18-65

Sorry, but we cannot offer a buddy to you if:

You do not consider yourself to be disabled
You have recently been detained or sectioned under the Mental Health Act
You need specialist support or advice to manage a mental health condition
You wish to attend hospital or other appointments
Any personal care is needed

Buddies for All will call the client within 5-10 working days to discuss their requirements in greater detail. If required, more information on our referral criteria can be found here: https://buddiesforall.org.uk/buddy-guidelines
Before proceeding with this referral please confirm you have understood the information above.*

Yes

Your details
Title*
Preferred Pronouns He/Him, She/Her etc.
Forename*
Surname*
First line of address*
Second line of address
Town / Area*
Postcode*
Date of birth*
Telephone number*
Secondary phone number (optional)
Email*
example@example.com
We hope to keep your client up to date with their match via email. It will not be shared with anyone. If you do not want to share their email address with us. or they do not have one. please enter N/A below.

Consent to record and use your personal information
Consent to record and use your personal information In order to provide a service for you, we need to record your personal details. Everything you tell us is treated confidentially and stored securely and you can ask to see a copy of your record at any time. Full details about how we manage your personal data can be found on our website https://buddiesforall.org.uk/privacy-policy or by calling 07759 306282.
I, the client, consent to Buddies for All CIC recording information about me in order to provide their services*

I agree
I agree I am happy to be contacted by * (Tick all that apply)*

PhoneEmailTextVoicemail
Consent to record and use your personal information*

I, the client, agree to a relative / professional / friend, including the person who refers me to Buddies for All CIC to discuss my enquiry with Buddies for All CICI, the client, agree to Buddies for All CIC discussing my enquiry with all relevant partners within the projectI, the client, consent to Buddies for All recording sensitive personal information about me, like health conditions or my ethnicity (known as 'special category data') for research and planning purposes only.I, the client, consent to Buddies for All CIC sharing my information with other service providers.
Signature

Clear

Buddies for All self-referral form