Facilitated Friendship 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)

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Referring Agent

Name*

Referral Date*

Address/Organisation*

Relationship to client*

Phone (work)*

Mobile*

Email*

Client

Name*

Date of Birth*

Address*

Street Address Address Line 2 City Postcode Country

Phone*

Mobile*

Email*

Details of disability (inc mobility aids used)*

Please turn over. Why would this person benefit from a Facilitated Friendship?*

Please give specific reference to any isolation issues

Please tell us about any friends they have lost touch with due to their mutual disability:*

Does the client live in accessible accommodation?*

Please give details