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Good Neighbour Self-Referral Form

Thank you for contacting Good Neighbours. Please use the form below to tell us about the support that you need for yourself*.

*If you would like to request support for someone else e.g. a client, friend or family member, 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.


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.

Who do we contact in an emergency?

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?

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?

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.

About Us

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