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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 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, gives 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 ^*

What gender do think describes you best? ^*

What ethnicity do you feel describes you best? ^*

Birth Date ^*

Street Address ^*

Ward ^*

Town ^*

Good Neighbours can only support Warrington residents.

Postal Code ^*

Phone Number ^*

Email (if they have one)

What support would you like?

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

support me to widen my social circle and find new friends

enable me to independently access shopping support via telephone / internet

support me to access community groups in my local area

connect me with a volunteer over the phone

encourage me to improve my mobility by accessing chair based exercises

connect to support to filling out forms

connect me to other services

Your Mental Health

At Good Neighbours we want to help. So we can provide you the best service we can, please pick which options describes you best. ^*

We never want to upset you consciously so it would be really helpful if you can share any triggers, subjects to avoid, activities or mentions that would cause you distress.

Again, so we don't create more of an issue, are there any dependancies or addictions that we should know about?

If nothing, please write N/A in the box

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.

Name of GP Surgery ^*

We use this in case of emergency to ensure your relevant records are sourced. It can also be useful should you ever need a prescription collected.

What are the health needs that affect me day to day? ^*

What are the current health conditions or challenges that affect my daily activities? This could be things like:

Hearing Impairment
Visual Impairment
Physical Challenges (our volunteers cannot push/transport wheelchair users)
Pain / Discomfort

Do you have a diagnosis of dementia?

Yes

I am awaiting diagnosis

Who do we contact in an emergency?

Please include their name, relationship to you and phone number

I dont have an emergency contact or ask that you contact no-one in the case of an emergency aside from the relevant Emergency Services.

You may wish to do this because there is no suitable emergency contact or you do not want anyone to be aware of any situation.

Referrer Information

If you are completing this form for someone else, please provide your information below.

First Name ^*

Last Name ^*

Position and Organisation ^*

Email ^*

Phone Number ^*

If you are a professional referring a person, is there anything we should consider to keep everyone safe and free from harm

Would prefer a male worker/volunteer only

Would prefer a female worker/volunteer only

Has multiple visitors/carers

Requires two representatives to visit/support

Has animals in the house

Safety hazards in home

Safety hazards in garden/entry

Poorly lit location

No close parking

Other concern

Is there anything else you think we should know?

Registered in England & Wales as a Registered Charity 1129343

01925 246880

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

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

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