Macfadyen Webb Referral Form

Macfadyen Webb 10-2 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.

Macfadyen Webb is a welcoming hub in Letchworth offering a range of activities for older and disabled adults. We are open from 10am - 2pm each Friday.

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.

Price and payment

You can pay by card or cash at the centre.
- Attendance including hot lunch & dessert: £10.45
- Attendance as above, including transport: £18
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: hubs@hils-uk.org

Client's details (person attending Macfadyen Webb)
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 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 Macfadyen Webb?
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 - 2pm 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

Contact 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:

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

What happens next?

Once you have submitted this form, we will be in touch with the client by telephone to confirm that we have received their referral, discuss when they would like to attend Macfadyen Webb, and answer any additional questions about the activities at the centre.

Please note that this is not a pre-requisite to attending the centre - Macfadyen Webb 10-2 club operates an open door policy, and so clients are welcome to drop in as convenient even if a referral has not been received. This referral simply makes it easier for our team to ensure that we are catering to your needs appropriately from the first time you visit.

We look forward to seeing you at Macfadyen Webb soon!
Other services

As well as meals on wheels and Communtiy hubs, 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?

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) 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 PRESS SUBMIT BELOW
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Client's details (person attending Macfadyen Webb)

Client Support Organisations

Referrer's (Your) Details

Client Wellbeing