Cuffley Day Centre Referral Form

Cuffley Day Centre Referral Form

Our Cuffley Day Centre is a warm and inviting space where older and disabled members of the community can enjoy a variety of activities, entertainment, and a two course lunch. The club is run by a team of highly trained and experienced staff members and volunteers who create a welcoming and engaging environment.

We have a range of activities on offer, including a daily lunch club, social activities, exercise classes, dance classes, bingo, crafts, and regular events to celebrate special occassions.

What kind of activities do we offer?

Cuffley Day Service offers a wide range of activities for both groups and individuals. Our staff take time to get to know you and discover your hobbies and interests, so that activities can be tailored to you. This ensures everyone gets the most enjoyment out of their time at Cuffley. Activities include:
- Sing-a-longs
- Bingo
- Quizzes
- Arts and Crafts
- Live musical performances
- Chair-based exercise
- Days out to local sights
Price & Payment

For £35 per session you will receive tea and toast on arrival, a two course hot dinner, and be able to participate in all activities.

Payment is required for one month’s sessions in advance and can be made by:
- Bank Transfer
- Our Zettle card reader at the club
- Cheque
Missed sessions will not be refunded unless there are extenuating circumstances.

Transport through Communities 1st available on request.

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: hubs@hils-uk.org

Client's details (person attending Cuffley Day Centre)
Name

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

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
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:

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 (this is the email we will send a copy of this referral to)
example@example.com
How did you hear about Cuffley Day Centre?
If you are filling this form in on behalf of someone else:

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)

Area CodePhone Number
Phone (other)

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

What happens next?

Once you have submitted this form, we will be in touch with the client (or their designated contact person) by telephone to confirm that we have received their referral, discuss when they would like to attend Cuffley Day Centre, and answer any additional questions about the activities at the centre.

We look forward to seeing you at Cuffley Day Centre soon!
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?
****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 Cuffley Day Centre)

Client Support Organisations

Referrer's (Your) Details

Client Wellbeing