<p> 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.</p><p>Initial Referral form for the Befriending Service Date______</p><p>Name of client : D.O.B______</p><p>Address:</p><p>Telephone Number:</p><p>Referrer’s name (if any)</p><p>If self referring please put self</p><p>Telephone Number:</p><p>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</p><p>Why would you like a befriender?</p><p>Are there any health issues you feel we need to know more about?</p><p>Contact name and telephone number in case of concern – relative, neighbour, social workers, etc</p><p>Please return this form to:</p><p>Rachel Lowery - Befriending Service, Volunteer Centre Buxton and District 16 Eagle Parade, Market Place Buxton SK17 6EQ Telephone 01298 23970</p><p>INFORMATION IS KEPT IN STRICT CONFIDENCE</p><p>1</p><p>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.</p><p>GP details:</p><p>Name or Doctor:</p><p>Address of Practice :</p><p>Telephone Number:</p><p>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)?</p><p>Have you any pets, if so what?</p><p>Regarding visits, what days would be more convenient to you? </p><p>What time of day? </p><p>Morning Afternoon</p><p>Is there any more information you would like to offer? </p><p>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.</p><p>Please see the Volunteer Centre’s handbook for other general information (including contacts, complaints procedures, confidentiality policy, etc).</p><p>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.</p><p>2</p><p>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</p>