Good Neighbour Beneficiary Referral Form

Thank you for contacting Good Neighbours. Please use the form below to tell us about the support needed for either yourself or the person you are referring to.

Please note that in order to use the Good Neighbours service, the person that is in need of support must be:

  • A Warrington resident
  • Feeling lonely with little or no contact with others the majority of the time
  • Have no family or friends to provide this support (for one off tasks)

If you/they only require assistance with a one-off task – please complete our task request form 

We encourage professionals to complete this referral form with your client, as the more background information we have the better the match we can make with a volunteer. Please ensure you have submitted as much information as possible, otherwise, the referral will be sent back to you and the support request will be delayed.

Declaration of Consent to Share
I confirm that I/the person I am referring to WVA Good Neighbours, give consent for personal information to be shared with volunteers and other relevant support organisations for the sole purpose of assisting with specific requests for help/support.

By checking the box you are confirming the information you are providing is true to the best of your knowledge

Some basic information

Please provide us with the basic information about the person requesting support
Gender

Good Neighbours can only support Warrington residents.

Please include their name, relationship to you and phone number

Your health and wellbeing

This section is about some of the challenges and conditions you might have.  This information helps us make sure you are communicated and supported in a way that suits your needs.

What are the current health conditions or challenges that affect my daily activities?  This could be things like:
  • Hearing Impairment
  • Visual Impairment
  • Mental Health
  • Physical Challenges (our volunteers cannot push/transport wheelchair users)
  • Pain / Discomfort

Do you have a diagnosis of dementia?

Who are the important people in your life?  This could a family or friends, people that you see at groups, worship or services.

What social support do you currently have in place?
We are asking this to try and get a picture of your week.
Are you currently linked with any other services?

It's sometimes useful for us to talk to someone who knows you very well to gather information about support we can provide. If you don't have anyone, put N/A in the box.

How we can help you

This section is about what you want to do and who you are.  We will make every effort to match you with a volunteer that shares your outlook and interests and this information helps us do that.

Let us know what you like.  This can be a favourite type of music, tv programme or film.  Perhaps an activity (gardening, walking, crafting)? Or a passtime (puzzles, jigsaws, table games)?

What are the things in your life you would want to change.  What keeps you well and happy?  For example:

  • Places locally you would like to go and people you would like to see
  • Important parts of your culture and faith


The things I would like for my future:
  • Attend social and hobby groups
  • Get out of the house and make friends in the community
  • Exercise and mobility
  • Improve my digital skills
  • Conversation and confidence

How can Good Neighbours support me?

Because our team are volunteers and there are risks and challenges to our work, we have a list of things we cannot offer:

  • Being the sole responsible carer for a person whilst family or friends run errands / take respite.
  • Personal care - bathing, dressing, feeding/drinking and administering medication, moving and handling (including wheelchairs)
  • Household - cooking, cleaning, repairs, gardening
  • Administration - completing forms, contacting providers, arranging services, banking
  • Transporting the person for any reason

Please bear in mind our service is delivered by volunteers and we may not be able to respond to bespoke or unique requests.

Have you had a fall and would like some more information on Keeping Mobile?

Keeping mobile is a service for those who have experienced a fall or who are frail and have a very high risk of a fall and may benefit from knowledge of low-impact strengthening exercises.

Referrer Information

If you are completing this form for someone else, please provide your information below.  This allows us to ask for follow-up questions or seek more information.  It is also useful for us to know where referrals come from.

Registered in England & Wales as a Registered Charity 1129343

01925 246880
The Gateway, 89 Sankey Street, Warrington, WA1 1SR

About Us

Warrington Voluntary Action supports the development of a vibrant, thriving and sustainable VCSE sector to meet the diverse needs of local communities.