Befriending referral form

This service is primarily in response to Covid-19 and aims to provide temporary and time-limited support to those who have been more effected by isolation. While some clients may be able to meet their Befrienders in person in the future, this is not something we can guarantee.

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)

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 Distance Befriender?*
Please give specific reference to any isolation issues
Would this person be interested in having a traditional, visiting befriender once social distancing is no longer required?*
Please state, to the best of your knowledge, how comfortable the client is on the phone, or using teleconferencing apps*
(e.g. WhatsApp voice/video, Zoom video calls, etc.)
Hobbies/Interests (to help assist with matching)*
Name
This field is for validation purposes and should be left unchanged.

Referring Agent

Client

Details of disability

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