Befriending referral form

Client Data Protection Notice:

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 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)

Befriending referral

Referring Agent
Name*
First Last
Organisation
Relationship to client*
Address*
Street Address Address Line 2 City Postcode Country
Email*
Phone (work)*
Phone (alternative)
Client
Name*
First Last
Date of birth*
DD slash MM slash YYYY
Address*
Street Address Address Line 2 City Postcode Country
Contact details*
Please let us know how best to get in contact with the client
Consent*
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)*
Email
This field is for validation purposes and should be left unchanged.

Befriending

Befriending referral

Referring Agent

Client

Details of disability

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