Befriending Referral Form

FAiR Befriending Referral form

Please complete this form as fully as possible to allow us to support you quickly and efficiently.

Please tick the relevant option

I am referring myself and consent to being contacted by a member of the team at FAiR I am a professional / community organisation / individual submitting this referral with the knowledge and consent of the person(s) nominated

Full name of person making referral (not required if this is a self-referral)

Name of referrer and contact details (not required if this is a self-referral)

Full name of person being referred (required)

Date of birth for person being referred (required)

Address, email and telephone number of person referred

Initial contact will be made on your preferred contact number

Referral details

Please tick the main reasons for your referral and provide extra details in the box below:

Mental health and wellbeing Loneliness/Isolation Information and Signposting to other services To build confidence and communication skills Other

Which type of befriending do you have in mind?

Taking part in FAiR activities Telephone befriending

Please Note we cannot offer urgent medical or financial help

Any other important contact information – please include any sensory or literacy needs

Purpose and Privacy Information

By submitting your details you consent to share information to improve our services to you. The data you supply on this form will be securely stored on our database. Your contact details will not be sold or shared with a third party. You can revoke your consent to this referral at any time by contacting FAiR directly. Our Privacy and GDPR policies and can be viewed on this website.

Consent (required)

I agree to the privacy policy.

Funded and supported by

We embrace and encourage Inclusion with our ethos of ‘FAiR for all’ through Companionship and Social interaction within our Rother community for all ages.

Get in Touch

[email protected]
07386 85 33 49

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HOME
OUR VISION & MISSION
OUR APPROACH
OUR TEAM
NEWS & EVENTS
CONTACT
GDPR Privacy Policy