Friends for Life - Resident Referral Form

1
Name of Referrer* This field is required.
First Name
Last Name
2
Contact Number
3
Email* This field is required.
4
Job title/relationship to resident
5
Care Home* This field is required.
6
Name of Resident* This field is required.
First Name
Last Name
7
Date of Birth of Resident* This field is required.
Date
Day
Month
Year
8
1. Has the resident given their consent for this referral to be made (if appropriate)?* This field is required.
Yes
No
9
2. Does the resident have a current Deprivation of Liberty Safeguard (DOLS), which may restrict activities undertaken in a visit?* This field is required.
Yes
No
10
3. Does the family agree for their family member's photo to be used on our Social Media / Website after they have passed away?* This field is required.
Yes
No
11
If yes, please give details below.
12
4. Please describe why the resident would benefit from regular contact from a volunteer befriender.* This field is required.
13
5. Does the resident have any cognitive, behavioural, sensory or disability issues that a potential befriender should be aware of?* This field is required.
Yes
No
14
If yes, please provide details below.
15
6. Hobbies/interests* This field is required.
16
7. Working life/occupation(s)* This field is required.
17
8. Family members/significant relationships* This field is required.
18
9. Country of origin and languages spoken* This field is required.
19
10. Any other relevant information
20
Signature
21
Date of referral* This field is required.
Date
Day
Month
Year
Should be Empty: