Good Neighbour New One Off | Warrington Voluntary Action

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

Acceptance of declaration

Some basic information

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

First Name ^*

Preferred Name

Last Name ^*

Gender

Female

Male

Transgender

Non-binary

Intersex

Prefer not to say

Birth Date ^*

Street Address ^*

Ward ^*

Town ^*

Good Neighbours can only support Warrington residents.

Postal Code ^*

Phone Number ^*

If applicable

Who do we contact in an emergency?

Their Name

Relationship to you

Phone number

What social support do you currently have in place? ^*

We are asking this to try and get a picture of your week.


	I DO see my family at least once a week
	I DON'T see my family at least once a week
	I DO see friends at least once a week
	I DON'T see friends at least once a week
	I attend a social activity or worship at least once a week
	I don't have any social support

How can Good Neighbours support me?

Prescription collection

Shopping to cover illness or emergency

One-off welfare check

I have a different request

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

What is the reason for your referral?

Illness or injury leading to short term inability to do it independently. We provide this support for up to 3 weeks.

Person is 'housebound'. A person will be deemed to be housebound when they are unable to leave their home environment through physical and/or psychological illness.

Change in circumstances. This could be that their source of regular support is temporarily unavailable.

Other

Shopping to cover illness or injury

Could a family member or a neighbour help you with your shopping?

Yes

When do you next require shopping?

Do you have any dietary requirements? (e.g. gluten free)

Shopping items

Here is the standard list we offer to shop for. We will ask for further information when we call you.

To use this service, please note you need to be able to reimburse the volunteer with cash on delivery of the shopping. Credit will not be allowed and our volunteers are never to be out of pocket.

Milk

Bread

Butter

Fruit (usually apples, oranges or bananas)

Teabags

Eggs

Readymeals (usually 3 or 4)

Additional item request

You can request more items here, please note that we may not be able to accommodate requests for luxury or risky items. We do not provide medicines, alcohol or certain chemicals.

Prescription collection request

When do you need your prescription collected?

What pharmacy do you use?

Is there anything we need to know?

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.

First Name ^*

Last Name ^*

Job Title ^*

Phone Number ^*

Email ^*