Pop-in Visit Referral Form

Pop-in Visit Referral Form

If you are finding this form difficult to fill in for any reason, you can request a paper form to be posted to you by callin 0330 2000 103.

Pop-in visits are conducted between 11.30am and 2:30pm, 7 days a week, 365 days a year. We can pop into any address in Hertfordshire.

Price and payment

£5.35 per visit.

We will send you a bill for the pop-in visits you have had at the end of every month. You can pay by:
- Debit or credit card over the phone or online
- Cheque
- Postal order

Provision of personal data: we cannot provide a service without a minimum amount of personal information. These sections of the form are mandatory on this form. Please ensure that you have the client’s permission to share their data, if you are completing the form on their behalf. Please see our full privacy statement on our website link below, or give us a call on the number above.

www.hils-uk.org/privacy-policy

Before you start

You can save the form at any time and return to it later by clicking the save button at the end of each page. If you do not want to create an account, you can skip this and either copy the link to your form, or provide an email address to receive a link to your draft form.

If you have any issues completing this form, please email: hertsmeals@hils-uk.org

Client's details (person receiving the visits)
Name*

First NameLast Name
Address Line 1*
Address Line 2
Town*
County*
Postcode *
Telephone*
Telephone (other)
Email
example@example.com
Date of birth

DayMonthYear
Date
Gender
Ethnicity
We are required for monitoring purposes to collect the ethnicity of all our clients to ensure the equality of our service. Please select the client’s ethnicity from the list above
Client Consent - please tick to confirm that:*

The client has been made aware of this referralThe client has been made aware of the charge for meals

Client Support Organisations

Sharing information about other services or organisations which support our clients, will help us to keep clients safe. This information will only be used to protect clients’ vital interests. Please provide this below:
Name of home care provider
Home care telephone number
Name of community alarm provider
Community alarm telephone number
GP Surgery
GP Telephone number
Other support service / professional
Other telephone number

Delivery and Access Details
Keysafe code (if applicable)
Keysafe location (if applicable)
Door entry code (for main building)
Any other access information (for instance, if the property is hard to find, is up flights of stairs, has limited parking, etc.)
Is there anything that could pose a risk to our staff when delivering? (for instance, others in the household, dogs that don’t like visitors, etc.)

Referrer's (Your) Details
Referrer Name*

First NameLast Name
Role or relationship to client *
Organisation (if applicable)
Phone number *
Email
example@example.com
How did you hear about HILS?
If you are filling this form in on behalf of someone else:

I confirm that I have obtained their consent to share their personal information with HILS, or have legal authority to consent on their behalf

Payment Details*

We will send a bill at the end of the month for the visits received during that month, so that you only pay for the visits you have received.

A monthly Direct Debit is the easiest and most reliable way to pay for your service. We recommend it for three main reasons:

1) Convenience: you won’t have to arrange payments every month;

2) Peace of mind: there will be no missed bills; and

3) Security: payments are protected by the Direct Debit Guarantee. We will send you the Direct Debit forms to complete with your Welcome Pack when you join the service.
Payment to be made by Direct Debit :*

YesNo (if no, please select an alternative below)
If you are unable to pay by Direct Debit, we can also accept payment via: credit or debit card online or over the telephone, cheque, or Postal Order. In some circumstances we can accept payment via an Allpay card or standing order, once you have spoken to our Finance Team to agree this. We never accept cash.
Payment method:

Credit or debit card (online or over the phone) Cheque Postal Order
Alternative payment methods: (to be agreed with HILS’ Finance Team)

Allpay cardStanding order
If someone other than the client is paying for the meal, please list their details here, and ensure their preferred payment method is selected above:
Alternative payer details

First NameLast Name
Relationship to client
Email
example@example.com
Address

Street Address

Street Address Line 2

CityCounty

Post code
I confirm that the payer above is aware and has given consent for their details to be shared with us and to be contacted regarding the client’s bill:

Client Support Contacts

It is very important that we have details of other people who we can contact if we have any concerns regarding the client’s health, safety, finances, or wellbeing. We can provide a better service if we have an emergency contact who is available between 11.30am and 2pm to answer the phone if required.

This is in case a client is not at home when we attempt to visit, we cannot find the client, and we are concerned for their welfare. We understand that not all contacts will be able to perform all support functions, so please tick the boxes to indicate who we should contact in which situation. If you can provide more than two contacts, please email these to us along with your form. Where possible please provide a mobile phone number.

If you do not have any contacts, please call our friendly team who may be able to help.
First Support Contact
Name *

First NameLast Name
Relationship to client*
Phone (primary) *

Area CodePhone Number
Phone (other)

Area CodePhone Number
Email
example@example.com
Please tick where applicable

Support contact is a keyholderContact about client whereaboutsContact about client health & wellbeingContact about client finances
Second Support Contact
Name

First NameLast Name
Relationship to client
Phone (primary)

Area CodePhone Number
Phone (other)

Area CodePhone Number
Email
example@example.com
Please tick where applicable:

Support contact is a keyholderContact about client whereaboutsContact about client health & wellbeingContact about client finances
Consent:*

I confirm that the support contacts above are aware, and have given consent, for their details to be shared with us and to be contacted in case of emergency

Other services

As well as pop-in visits, HILS also delivers a number of other services to help people remain happy, healthy, and independent in their home. If the client is interested in receiving further information about any of our other services, please tick below and our Support Team will get in touch.
Which additional services is the client interested in receiving?

Physical activity and exercise at home(free) Medication prompts / reminders (free) **** Key safe installation (£) Help from an Optician at home (free) Advocacy: help with decision making around your care and support (free) Dementia support or fun clubs (£)
****PLEASE NOTE: we can only accept requests for medication prompts from a professional who can confirm that the client has the capacity to manage, dose, and self-administer their medication.

END OF FORM
Please verify that you are human*
Date

DayMonthYear
Date
Should be Empty:

Client's details (person receiving the visits)

Client Support Organisations

Delivery and Access Details

Pop-in Service Details

Referrer's (Your) Details

Client Wellbeing