Refer yourself (Self Referral Form)

Full name *

Title *

What would you like us to call you? (e.g. 'Mrs Brown' or by your first name if you prefer) *

Where did you hear about us? *

Preferred method of contact *

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

Telephone *

Email address (if you have one)

Address *

Postcode *

Date of birth *

Do you have a disability? *

Yes

No

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

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

Yes

No

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

Gender *

	Male	Female	Transgender	Prefer not to say	Prefer to self-describe
Please tell us about your gender: *	Please tell us about your gender: - Male	Please tell us about your gender: - Female	Please tell us about your gender: - Transgender	Please tell us about your gender: - Prefer not to say	Please tell us about your gender: - Prefer to self-describe
Self-describe gender:	Self-describe gender:

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

What is your ethnicity? *

Self describe ethnicity

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

Next of kin/Emergency contact

Name (Next of kin/Emergency contact) *

Emergency contact number *

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

We can support you 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? (If you'd like telephone friendship, mention it here)

1: *

2:

Are you currently receiving support from another organisation or service? *

Yes

No

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

How would you rate your general feeling of wellbeing? From 1 to 6 rate how you 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

Do you provide consent for us to contact you? *

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 support the person. *

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

Refer yourself (Self 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.