Self Referral Form

FAiR Self-Referral form

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

Referrer Details

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 referring an individual and have gained consent from the individual to make this referral

Full name of person being referred (required)

Date of birth for person being referred (required)

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

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

Preferred contact details for person being referred (required)

Other contact details

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

Referral details

Which type of befriending do you have in mind? Don’t worry if you’re not sure, we can talk about it:

Taking part in FAiR activities Telephone befriending Home visit befriending Care Home / Supported Living befriending Support to use community facilities (general) Support to attend community group or service (specific)

Please tell us more about the reasons for the referral

Purpose and Privacy Information

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than seven days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent and change my mind about referral at any time by contacting FAiR directly. Our privacy policy can be viewed on this website.

Not for urgent medical or financial help (required)

Yes, I understand THIS FORM IS NOT for urgent medical or financial help

Consent (required)

I agree to the privacy policy.

FAiR Self-Referral form

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

Referrer Details

Referral details

Purpose and Privacy Information

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