Initial Referral Form for the Befriending Service Date______

16, Eagle Parade, Buxton SK17 6EQ Telephone: (01298) 23970 Fax: (01298) 70713 e-mail:[email protected] www.buxtonvb.care4free.net Office Hours: 9.30am to 4pm Patron: His Grace The Duke of Devonshire, M.C.

Initial Referral form for the Befriending Service Date______

Name of client : D.O.B______

Address:

Telephone Number:

Referrer’s name (if any)

If self referring please put self

Telephone Number:

Does the client know they are being referred? (please note we cannot accept referrals without permission nor pass on information about the client) Yes/No

Why would you like a befriender?

Are there any health issues you feel we need to know more about?

Contact name and telephone number in case of concern – relative, neighbour, social workers, etc

Please return this form to:

Rachel Lowery - Befriending Service, Volunteer Centre Buxton and District 16 Eagle Parade, Market Place Buxton SK17 6EQ Telephone 01298 23970

INFORMATION IS KEPT IN STRICT CONFIDENCE

Supported by North Derbyshire Health Authority, Derbyshire County Council, Borough of High Peak and the Community Fund. Registered Charity No.1067193 A Company Limited by Guarantee Registered in England No: 2918492. Reg. Office: 16, Eagle Parade, Buxton SK17 6EQ 16, Eagle Parade, Buxton SK17 6EQ Telephone: (01298) 23970 Fax: (01298) 70713 e-mail:[email protected] www.buxtonvb.care4free.net Office Hours: 9.30am to 4pm Patron: His Grace The Duke of Devonshire, M.C.

GP details:

Name or Doctor:

Address of Practice :

Telephone Number:

Is there anything else we need to know regarding access to the premises (e.g. which door to use, handover/key safe information), other visitors (home helps, etc)?

Have you any pets, if so what?

Regarding visits, what days would be more convenient to you?

What time of day?

Morning Afternoon

Is there any more information you would like to offer?

This information will be reviewed 6 monthly, however, if you would like to make any changes, please contact the Volunteer Centre on the above telephone number.

Please see the Volunteer Centre’s handbook for other general information (including contacts, complaints procedures, confidentiality policy, etc).

If you would like to discuss our procedures or if you would like a copy of any of our policies, please also contact the Volunteer Centre.

Supported by North Derbyshire Health Authority, Derbyshire County Council, Borough of High Peak and the Community Fund. Registered Charity No.1067193 A Company Limited by Guarantee Registered in England No: 2918492. Reg. Office: 16, Eagle Parade, Buxton SK17 6EQ