Make a Referral

If you would like advice or help from The Friendly Trust or you want to find out if we can help someone you know, please complete the form below. We want to help as many people as possible and all advice given is free.

Referral Form

Full Name*

Date of Birth*

National Insurance Number*

Address Line 1*

Address Line 2*

City*

Postcode*

Phone*

Date moved to this address*

If less then 3 years please give details of previous address/es

Details of disability/disabling illness/vulnerability*

Living situation

If the service is to be paid for by a local authority, please give details and confirm that you have authority to make the referral

If the service is to be paid for by someone else, please give details and confirm that you have their permission to give this information

Self funded? Does the vulnerable person have capacity and consent to charges?

... or has a Best Interest meeting taken place?

Summary of initial Referral*

Name of person making the referral*

Email of Person making Referral*

Relationship to person being referred*

Contact number of person making the referral*

Please tick to confirm you have read and agree to our Privacy Notice which can be found below*