Friends for Life - Resident Referral Form
Name of Referrer
*
First Name
Last Name
Contact Number
Email
*
Job title/relationship to resident
Care Home
*
Name of Resident
*
First Name
Last Name
Date of Birth of Resident
*
-
Day
-
Month
Year
Date
1. Has the resident given their consent for this referral to be made (if appropriate)?
*
Yes
No
2. Does the resident have a current Deprivation of Liberty Safeguard (DOLS), which may restrict activities undertaken in a visit?
*
Yes
No
If yes, please give details below.
3. Please describe why the resident would benefit from regular contact from a volunteer befriender.
*
4. Does the resident have any cognitive, behavioural, sensory or disability issues that a potential befriender should be aware of?
*
Yes
No
If yes, please provide details below.
Further information about the resident will help FFL to match them with the most suitable befriender. This may involve shared interests, background, or even language. Please provide as much detail as you can about the resident:
5. Hobbies/interests
*
6. Working life/occupation(s)
*
7. Family members/significant relationships
*
8. Country of origin and languages spoken
*
9. Any other relevant information
Signature
Date of referral
*
-
Day
-
Month
Year
Date
Submit
Should be Empty: