Compassionate Neighbour Referral Form

Referral criteria: This project offers support to residents of Merton and Sutton who are approaching the end of life (due to frailty or illness) and who are socially isolated, their carer or the bereaved.

Please confirm you or the person you are referring on behalf of fit the criteria. (If not, we are unable to accept the referral) (required)

Yes

Person in need of a Compassionate Neighbour

First name (required)

Last name (required)

Telephone number(s) (required)

Email address (required)

Address (Merton and Sutton only) (required)

Postcode (required)

Date of birth (required)

If referring on behalf of someone else

Has the person agreed to the referral and being contacted by us? (required)

YesNo (If not, we are unable to accept the referral)

Referrer name (required)

Referrer organisation or relationship to person (required)

Referrer telephone number(s) (required)

Referrer email (required)

What is the reason for the referral (required)

Compassionate Neighbours offer companionship, emotional support, a listening ear, practical support and help to integrate / connect with the local community. What support is required? (required)

Are there any health or behaviour factors that we should be aware of prior to our assessment? (required)

Any other information you would like to provide:

I agree to referral details to be stored securely on the St Raphael’s database (required)

Yes

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