Making Connections Walk and Talk Self Referral Form
Referrals are accepted by people over 65 in Dublin South/ South East (HSE Community Healthcare East CHN’s 1- 6). Please note: you will receive a copy of the completed form by email after submission
SERVICE SELECTION
I am making a self referral for:
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Making Connections Walk & Talk Programme Leopardstown
Making Connections Walk & Talk Programme Churchtown
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Your Details
1.1 Name
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First Name
Last Name
1.2 Date of birth (participants for the Walk and Talk must be 65+)
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-
Day
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Month
Year
Date
1.3 Phone number(s)
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1.4 Email Address (if applicable)
example@example.com
1.5 Address
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Address line 1
Address line 2
Area
County
Eircode
1.6 GP Name + Practice
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Emergency Contact Person
This can be a next of kin or other suitable person. In case of emergency, we need to be able to contact a nominated person. This is an essential requirement of the Walk and Talk Programme.
2.1 Name
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First Name
Last Name
2.2 Relationship to you
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2.3 Location (County/ Country)
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2.4 Personal Mobile Number
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Final Section - Questions
1. Do you have any concerns about your memory?
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2. Can you prepare your own meals independently?
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Yes
No
2.1 If you answered 'no': (tick all that apply)
Meals on Wheels
Ready prepared meals
Family or carer completes
3. Can you manage your personal activities independently i.e washing, dressing etc.?
4. Do you complete you own shopping?
5. How do you propose to get to the Walk and Talk venue?
6. Do you have any requirements that we need to be aware of to make your experience on the programme more comfortable?
** If you are unable to complete the questions above independently, then a nominated individual will need to be present with you for all the sessions.
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I consent to my data being stored in accordanceto the Making Connections GDPR Policy.
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