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 * REQUIRED
First Last
Organisation
Relationship to client * REQUIRED
Address * REQUIRED
Street Address Address Line 2 City Postcode Country
Email * REQUIRED
Phone (work) * REQUIRED
Phone (alternative)
Client
Name * REQUIRED
First Last
Date of birth - must be dd/mm/yyyy format * REQUIRED
Date Format: DD slash MM slash YYYY
Address * REQUIRED
Street Address Address Line 2 City Postcode Country
Contact details * REQUIRED
Please let us know how best to get in contact with the client
Consent * REQUIRED
My client has given consent.
Details of disability
Details of disability * REQUIRED
Please include description of any mobility aids used
Why would this person benefit from a Befriender? * REQUIRED
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? * REQUIRED
(please give details)
Hobbies/Interests (to help assist with matching) * REQUIRED
Comments
This field is for validation purposes and should be left unchanged.

Referring Agent

Client

Details of disability

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