First Contact / Third Party Referral Form

Your details - Third party referrer (person or organisation)

Referrer's name *

Organisation / Service (write N/A if this is not applicable) *

Your role or your relationship to the person you are referring (e.g. friend, carer, social worker etc.) *

Referrer's email *

Referrer's telephone *

Full name of the person being referred *

Title *

What would the person you are referring like us to call them? (e.g. 'Mrs Brown' or by their first name if they prefer) *

Where did you hear about us? *

How should we contact the person you are referring? *

If 'Other', tell us what method of contact they'd prefer

Their telephone number *

Their email address (if they have one)

Their address *

Their postcode *

Their date of birth *

Their gender *

	Male	Female	Transgender	Prefer not to say	Prefer to self-describe
Please ask the person you are referring tell us about their gender: *	Please ask the person you are referring tell us about their gender: - Male	Please ask the person you are referring tell us about their gender: - Female	Please ask the person you are referring tell us about their gender: - Transgender	Please ask the person you are referring tell us about their gender: - Prefer not to say	Please ask the person you are referring tell us about their gender: - Prefer to self-describe
Self-describe gender:	Self-describe gender:

Their sexual orientation *

	Heterosexual or Straight	Gay or Lesbian	Bisexual	Other sexual orientation	Prefer not to say	Prefer to self-describe
Which of the following options best describes how the person thinks of themselves? *	Which of the following options best describes how the person thinks of themselves? - Heterosexual or Straight	Which of the following options best describes how the person thinks of themselves? - Gay or Lesbian	Which of the following options best describes how the person thinks of themselves? - Bisexual	Which of the following options best describes how the person thinks of themselves? - Other sexual orientation	Which of the following options best describes how the person thinks of themselves? - Prefer not to say	Which of the following options best describes how the person thinks of themselves? - Prefer to self-describe
Self-describe sexual orientation:	Self-describe sexual orientation:

Tell us about their ethnicity *

Self described ethnicity

If their first language is not English, please tell us what it is.

Do they have a disability? *

Yes

No

If you answered 'Yes', please provide more details here

Do they have any medical or health issues, including mobility, mental health or cognitive issues? *

Yes

No

If you answered 'Yes', please provide more details here

Are there any identified risks (to self or others) we should be aware of? This should include whether a safeguarding concern/alert has been made. *

Yes

No

If you answered 'Yes', please provide more details here

Their Next of kin / Emergency contact

Name (Next of kin/Emergency contact) *

Emergency contact number *

What two concerns or problems would they most like us to help with?

We can support them with up to two concerns/problems.

Concern/Problem 1 *

Concern/Problem 2

In what two ways do you think we’ll be able to help them?

1: *

2:

Are they currently receiving support from your organisation or another service? *

Yes

No

If you answered 'Yes', please provide more details here

How do they rate their general feeling of wellbeing? From 1 to 6 rate how they are feeling today. 1 being as good as it could be, and 6 being as bad as it could be *

	1	2	3	4	5	6
Select one *	Select one - 1	Select one - 2	Select one - 3	Select one - 4	Select one - 5	Select one - 6

Consent

Without consent of the person being referred we cannot accept this referral.

Is the person you are referring aware of this referral and have you gained their consent? *

Yes

No

We will store the information on this form securely. In order to provide support we may share it with Public Voice, Mind in Haringey, HAIL/Vibrance, Haringey Over 50s Forum, Wise Thoughts or any other organisation who may be able to provide support. *

Tick here if you agree with everything written on this form.

Tick here if you are happy for us to share this information in order to provide you with the best support.

Tick here if you are not happy for us to share this information.

Happy healthy lives for over 50s

First Contact / Third Party Referral Form

Haringey Reach and Connect is an independent service. We provide short-term support (5-10 hours in total) for residents over 50. We are not a statutory or Council service.