Befriending referral form

Ecas will use the information supplied on this form, including information about the client’s health to assess their eligibility and to administer our client records. By submitting or returning this form, the client has consented to Ecas processing their data for those purposes.

Please ensure you have read the referral criteria before completing this form.

Download application form (Word document)

Referring Agent
Name
First Last
Organisation
Relationship to client
Address
Street Address Address Line 2 City Postcode Country
Email
Phone (work)
Phone (mobile)
Client
Name
First Last
Date of birth - must be dd/mm/yyyy format
Date Format: DD slash MM slash YYYY
Address
Street Address Address Line 2 City Postcode Country
Phone
Phone (mobile)
Consent * REQUIRED
My client has given consent.
Details of disability
Details of disability
Please include description of any mobility aids used
Why would this person benefit from a Befriender?
Please give specific reference to any isolation issues
Does the client have any disabled friends who he/she has lost touch with due to their mutual disability?
- Yes
- No
Please give details
Does the client live in accessible accommodation?
(please give details)
Hobbies/Interests (to help assist with matching)

Referring Agent

Client

Details of disability

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