Step 1 of 7

14%

Comments

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

Are you interested in volunteering or would you like to make a referral?(Required)

I am interested in volunteering

I want to make a referral

Referrer Details

Referrer's name(Required)

First Last

Organisation (if applicable)

Email(Required)

Phone

Would you like to be informed of the outcome of this referral(Required)

Yes

Details of the person who would like support

Please do not share private medical information on this form.

Name of person you are referring(Required)

First Last

Phone

Address

Street Address Address Line 2 Town County Postal Code

Date of birth

Preferred language

Would you describe them as lonely and / or socially isolated?(Required)

Yes

Unfortunately, if they don't meet this criteria, we cannot accept their referral

Has the person given their consent to be referred to this service?(Required)

Yes

Unfortunately, if they don't meet this criteria, we cannot accept their referral

Is the person willing to be contacted by telephone?(Required)

Yes

Is the person willing to be contacted by email?(Required)

Yes

Is the person willing to receive a letter by post?(Required)

Yes

Does the person need a translator for their first home visit?

Yes

Additional Details

Do they have any pets(Required)

Yes

Please specify(Required)

Do they smoke?(Required)

Yes

Does this person have any long-term health conditions?(Required)

Yes

Please specify(Required)

Are there any potential behavioural issues we need to be aware of prior to a home visit?(Required)

Yes

Please specify(Required)

What is the access to the property like?

Do they live alone?

Do they have regular visitors? If so, who?

What other support do they receive?

Do they have another befriender visitor?

Compassionate Neighbours is a two-way friendship. Please describe what the person you are referring could bring to a mutually beneficial befriending relationship? Consider their interests and how they connect and engage with others.

Reason for referral(Required)

What sort of help/support is required(Required)

Any other information

Next of kin details

Next of Kin name(Required)

First Last

Relationship(Required)

Phone(Required)

Other information:

Volunteer Details

Name

First Last

Phone

We’d love to keep in touch with you from time to time, about volunteering opportunities, sharing news and fundraising information or events.   Please tick below to tell us how you wish to hear from us: 

Email(Required)

Yes, I'm happy to hear from you by email

No, please don't email me, other than to respond to my enquiry

Phone calls and text messages(Required)

Yes, I'm happy to hear from you by phone or text message

No, please don't phone or text me, other than to respond to my enquiry

We promise to keep your details safe, and we will never sell or share them with anyone.  Our privacy policy explains how we keep this promise to you.   If you change your mind in future about how you would like to hear from us, please email  preferences@hokh.co.uk or call 01622 792200

CAPTCHA

Compassionate Neighbours Referral

Refer yourself or someone else who would benefit from having a Compassionate Neighbour here.

Referrer Details

Details of the person who would like support

Additional Details

Next of kin details

Volunteer Details