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Good Neighbour Beneficiary Referral Form

Thank you for contacting Good Neighbours. Please use the form below to tell us about the support that is needed for someone else e.g. a client, friend or family member*.

*If you would like to request support for yourself, please complete this form.

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

  • A Warrington resident
  • Unable to carry out activities independently due to health, age, disability or other barriers
  • Have no-one else in their support network that can assist

To learn about the support we offer click here.

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.

Please confirm ...
I confirm that the person I am referring to WVA Good Neighbours has given their consent for their personal information to be shared with volunteers and other relevant support organisations for the sole purpose of assisting that person with their own specific requests for help/support.
Your Details

Please provide your organisation's name in full

Your Position
Person you are referring

Please ensure you use numbers only, formatted dd/mm/yyyy.

This project is only available to residents of Warrington.

Please provide name, relationship and phone number.

Support Requested

PLEASE NOTE: This is for individuals who are socially isolated and with no-one else who you/they can rely on for support (and tasks you/they are unable to perform themselves).

Please be aware that these tasks are carried out by volunteers, therefore we can not ensure when a task will be done. If the referral is for prescription collection or shopping, these requests can not be delivered at a set time, it can take up to a week to process requests and find an available volunteer.

What support is requested?
Select a maximum of 3
Do they live alone?
We may prioritise requests from people who identify as being isolated and living alone.
Do they have a diagnosis of dementia?
This is asked to ensure we can match with an appropriate volunteer.
Do they struggle with Mental Health conditions?
This is asked as we are a befriending service, our volunteers are not trained to give mental health advice.

This includes and hearing problems, mobility issues and anything which could affect your befriending. Feel free to include any interests or hobbies in here too and we might be able to find a volunteer who has similar interests. *PLEASE NOTE we are unable to provide in person support to wheelchair users

Shopping Details

PLEASE NOTE: Our shopping requests are done by volunteers, therefore we can not guarantee when the shopping will be delivered as it is dependent on volunteer availability. WE DO NOT TAKE SHOPPING REQUESTS ON FRIDAYS, they will be picked up the following week.

We have a set shopping list of:

Milk, Bread, Eggs, Butter, Ready meals, Fruit and Tea bags. 

If any additional items are required (such as toiletries or drinks) they need to be put in the additional items box to be added to the list and if there are any allergies or intolerances they must be stated where asked. 

Could a family member or a neighbour help you with your shopping?
Are you able to sign up to our cashless reimbursement system online?

About Us

Warrington Voluntary Action supports the development of a vibrant, thriving and sustainable third party sector to meet the diverse needs of local communities. Our values revolve around being passionate, whilst thinking creatively and working collaboratively with others.