INFORMATION

Office Hours:

Wednesday

9:30am - 12pm

Thursday

9:30am - 12pm

 

Referral Form

IVYBRIDGE CARING

REFERRAL FORM

Date of Referral………….…….  
Has client agreed to accept Ivybridge Caring? Yes / No

Is this a self-referral? Yes / No

If no, who is referring? Name ……………………….. Position…………. …………………

Organisation ……………….…..……. Tel …..……………….. Email ………………………
             

Name of potential client ………………………………          Date of birth ………………………

Address …………………………………………………………………………………………….

…………………………………………………………………. Postcode …………………...…

Tel No …………………………………                                  Ethnic origin …………………………..

GP name ………………………………      Practice name ………………………………………….

Disabilities ………………………………… Key worker ………………...........Tel ………………..

Does client live alone? Yes / No    If no, names of other occupiers of dwelling:

         Name ……………….…………           Name ………………………………
                                               
        Relationship ………………….            Relationship ………………………

Is client a smoker? Yes / No* *NB Ivybridge Caring adopt the official NHS smoking policy with regard to outreach workers, whereby the client needs to refrain from smoking half an hour before our worker is due to arrive, and refrains from smoking whilst the worker is present.

Next of kin ………………………………….….           Tel ……………………………..………

To be completed by co-ordinator:

Contacted client on ……………………..                 Visited client on ………………………….

Support commenced on …………………….          Volunteers name …………………..

Ivybridge support ended ……………….      Not matched ……………………………

Referred on to …………………………………………………………………………….

So that we can offer the client appropriate support and match the most suitable volunteer, please indicate the type of support required. 

 

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Why is this a need? How would the client like the volunteer to help?

Companionship

 

 

Help with socialising

 

 

Collecting  
prescriptions

 

 

Shopping

 

 

Dog walking

 

 

Low level help in home

 

 

 Provision of information   
 for professional and    
 other useful services

 

 

 Other

 

 

Background and any other additional information i.e. Medication

 

 

Are there any health and safety issues that we need to consider when placing a volunteer with this client?
 ie pets, access, smoking

 

 

NB: If not self-referral, please note that any information provided can be shared with the client.
Data protection Act 1998: Client names and addresses are stored on our computer system for administrative purposes, and are only available to other parties following the express consent of the client concerned.

 

I have read and agreed with the above and accept a visit from the Ivybridge Caring

 

Client Signature ……………………………………………… Date ………………………..

 

Referrer Signature (if relevant) …………………………… Date ..………………….……