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.?
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4. Do you complete your own shopping?
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5. Do you drive or take public transport?
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6. How do you propose to get to the Walk and Talk venue?
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7. Do you have any requirements that we need to be aware of to make your experience on the programme more comfortable?
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** 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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