Befriending Referral Form

Before filling in this form please read our Befriending criteria. Please fill in as much detail as possible.

Are you referring for (Please note we might at assessment decide someone is better suited to face-to-face or telefriending depending on how they match our criteria)

Face-to-Face Befriending (only for people living in London)Telephone Befriending For anyone living in the UK (including the Out Together Telefriending Partnership in West Yorkshire)Happy with either

How did you hear about the Befriending Service?

Client’s Name

Do they know they’re being referred? (required)

Address (please specify which borough) (required)

Telephone number: (required)

Email address

Gender including pronouns: (required)

Sexuality (required)

What is their ethnicity?

What is your religion/belief/faith?

If other, please specify:

Date of birth (Client must be over 50) (required)

Preferred language spoken (required)

When are the best times/day for them to receive their call/ visit? (required)

Reason for referral (required)

Current social contacts (e.g. lunch clubs, social groups, friends/family…) (required)

Care

What sort of support or care does the client have? (required)

Only a cleaner / gardenerFunded care packageFamily or Friends / neighbourPrivate care packageNone

Name/ contact details of care agency, carer or person organising care (required)

When and how often does the carer come? (required)

Is there anyone else who the client relies on for support who you can provide contact details for and may help us assess or contact the client? Phone/email/mobile (required)

Emergency contact or Next of Kin (Name, relationship mobile, email, post code) and/ or GP practice if not one (required)

Risks

Are there any risk factors that we need to be aware of? YES/NO (If yes, complete the following)

Yes No

Risk to themselves

Environmental hazards such as house clutter or smoking?Self-neglectAbuse from someone. Is this abuse physical or other?Forgets appointments/people?

Risk to others

Environmental hazards such as house clutter or smoke, pet?Violence/aggression from client?Anxiety or suspicions that could affect service provision?

Any other comments about potential risks

Referral Details

Your name (required)

Organisation name (if applicable)

Are you

Social servicesGPSupport/ Care workerLocal Age UKFamilyMental health serviceCharity

Other (please specify)

How long have you been/ will be in contact with the client? (required)

Email (required)

Telephone Number (required)

How did you hear about us? (required)

Date