ࡱ > b d a U ; bjbjnn 44 aa} 8 * $ N t ) t ( ' ' ' ( ( ( ( ( ( ( $ z* 0- p ( ! " ' ! ! ( ( -$ -$ -$ ! ^ 8 ( -$ ! ( -$ -$ -$ P)q " ^ -$ q( ( 0 ) -$ - i" - -$ -$ - A$ 0 ' v T -$ D 5 x ' ' ' ( ( 9# ' ' ' ) ! ! ! ! - ' ' ' ' ' ' ' ' ' B T : REFERRAL FORM Client Data Protection Notice: Ecas will use the information supplied on this form, including information about the clients 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. REFERRING AGENT: NAMEREFERRAL DATE ADDRESS/ORGANISATION RELATIONSHIP TO CLIENT PHONE WORK MOBILEEMAIL CLIENT NAME D.O.B. ADDRESS PHONEMOBILE EMAIL CONSENT GIVEN DETAILS OF DISABILITY (inc mobility aids used) Please turn over 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? If YES please give details. Does the client live in accessible accommodation? (please give details) Hobbies/Interests (to help assist with matching). Additional Information Thank you for completing this form. Please email to HYPERLINK "mailto:ally@ecas.scot" ally@ecas.scot or return it to Ecas, Norton Park, 57 Albion Road, Edinburgh EH7 5QY. Ecas will be in touch as soon as possible. Ecas full privacy notice can be found here: HYPERLINK "https://www.ecas.scot/privacy" https://www.ecas.scot/privacy Ecas Ltd: a company limited by guarantee in Scotland No. 102790, registered office Norton Park. 57 Albion Road, Edinburgh, EH7 5QY. Registered Charity Number: SC014929 . k 8 9 : Z l ƵƵxix^xVRNJRFBR h# hcY hr h0 h hc h 5h0 5>*CJ aJ h0 h0 56>*CJ aJ h0 h0 5>*CJ aJ h0 h0 CJ aJ $h+ h-1 5B*CJ ^J aJ ph !h+ heAr B*CJ ^J aJ ph !h+ h0 B*CJ ^J aJ ph $h+ h0 5B*CJ ^J aJ ph h0 h0 CJ aJ h0 hRZ 5>*CJ aJ h0 hLl" 5>*CJ aJ . 9 : $If gd gd gd0 gd 7$ 8$ H$ gd0 gd0 $a$gd0 ~ u u $If gd