Name of referrer *:

Job title of referrer/relationship to client *:

Address of organisation *:

Telephone number:

Email *:

Is client/family aware of referral?:
YesNo

Client Details

Client Title and Name:

Landline Telephone No:

Mobile Telephone No:

Email Address:

Address Line 1:

Address Line 2:

Town:

County:

Postcode:

Date of Birth:

Gender:
MaleFemaleTransgenderOtherPrefer not to say

Preferred pronouns:
HeSheTheyOtherPrefer not to say

Ethnicity/Languages spoken:

Wheelchair user?:
YesNo

Do you consider yourself to have a disability?:
YesNo

Do you have a Blue Badge?:
YesNo

Religion or Belief:
No ReligionFaith
If Faith please state which:

Employment Status:
RetiredEmployedUnemployedOther

Relationship Status:
SingleMarriedCivil PartnershipCohabitingWidowedDivorced

Sexuality:
HeterosexualLesbianBisexualGayOtherPrefer not to say

Client Emergency Contact/NOK Details/Carer’s details

Name:

Relationship to Client:

Telephone number:

Client’s GP Details

GP Name:

Telephone number:

GP Practice Address :

Client’s Medical History

Brief medical information, e.g. Diagnosis, what does the client understand about the diagnosis /prognosis?
Treatment Plan, Medication, Physical and emotional state, Mobility and degree of dependency on carer:

Additional information

Risks to be aware of:
Please include health & safety, safeguarding concerns, family dynamics, transport or property access issues, Pets etc?

Are other members of the family aware of the client’s condition?
YesNo

Is any other agency providing services?:
YesNo
If Yes, please specify:

What would the client like support with? (tick all that apply):
Befriending face to faceTelephone befriendingRespite sittingSocial groupWalking groupCounsellingHospital transport
Befriending/respite support (Preferred times for visits):

Does the client need a volunteer of a specific gender? (Please only specify if this would impact on the relationship):
No preferenceMaleFemale

Declaration

Being There collects personal information in order to provide the right support service and volunteers for your need. Data is kept on a password protected, secure database. We keep your data on record until the nearest financial year end to when you stopped using our service. We do this in order to collate anonymous annual statistics for service monitoring purposes. If our services are not appropriate to your needs we may refer you to another organisation such as a charity or the NHS. Your consent would be required in order to do this. We also share your basic contact details with the volunteer that is agreed to provide support to you. You can request to see what data we hold on you at any time. We will provide the data within two weeks of request as a printed document sent to your home address.

I consent to Being There processing my personal details in line with the Privacy Notice

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