Facilitated Friendship self-referral

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)

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URL

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Personal Details

Name*

Date of Birth*

Address*

Street Address Address Line 2 City Postcode Country

Phone*

Mobile*

Email*

Referral Date*

Details of disability (inc mobility aids used)*

Do you live in accessible accommodation? (please give details):*

Please turn over Please tell us about any friends who you have lost touch with due to your respective disabilities:*

Why would you benefit from a Facilitated Friendship?*

Please give specific reference to any isolation issues