Kingfisher Club Referral Form

HILS Willow Group Dementia Club 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 calling 0330 2000 103.

Our Willow Group, run from Friendship House in Hatfield, is welcoming and engaging, with every session offering an exciting mix of activities. Our club is run by highly-trained staff supported by a team of caring volunteers.

Activities
Our group offers a wide range of both group and individual activities. We work with you to understand your hobbies and your life story. We do this so that we can create activities that centre around your interests.
Previous activities have included:
- food tasting
- information sessions
- poetry readings
- sing-a-long sessions
- debates
- quizzes
- crafts and carpentry
Eligibility:
Our group is for people living with mild to moderate dementia. You can join if:
- you’re not violent or aggressive towards others
- you can go to the toilet by yourself
- you don’t have a tendency to wander
- you can eat a meal without help
Locations & Dates:
Monday, Wednesday, and Fridays: Friendship House, Wellfield Close, Hatfield, AL10 0BU

Should your needs change while you are a member of the club, we will help direct you to other services that may be more suited to supporting you.

If you would like to refer someone to attend the Kingfisher Club, please complete the form below. Once we receive this form, we will add you to the client waiting list. We will be in contact with you closer to the time to confirm exact club details, and start dates.

Client's details (person attending the Club)
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
Which day/s would the client like to attend?

MondayWednesdayFridayUnsure
Client Consent - please tick to confirm that:*

The client or appropriate representative (e.g. power of attorney) has been made aware of this referral

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:
GP Surgery
GP Telephone number
Other support service / professional
Other telephone number

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' Dementia Clubs?
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

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 10am - 3pm to answer the phone if required.

This is in case a client attends the centre we are concerned for their welfare, or there is an instance of illness or injury. 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)
Email
example@example.com
Phone (other)
Please tick where applicable

Contact about client whereaboutsContact about client health & wellbeingContact about client finances
Second Support Contact
Name

First NameLast Name
Relationship to client
Phone (primary)
Phone (other)
Email
example@example.com
Please tick where applicable:

Contact 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

Which additional services is the client interested in receiving?

Meals on wheels delivered to your door (£)Physical activity and exercise at home (free) Medication prompts / reminders (free) **** Key safe installation (£) Advocacy: help with decision making around your care and support (free)
****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 PRESS SUBMIT BELOW
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Client's details (person attending the Club)

Client Support Organisations

Referrer's (Your) Details

Client Wellbeing