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.

If you are making a referral on behalf of someone else, please get their permission if you can.

Dear PROFESSIONALS: If you are cannot obtain someone’s permission because, for example, the person lacks mental capacity, please make sure that you have the proper authority to pass on their personal details to The Friendly Trust. If in doubt, speak to your manager.

Referral Form

FULL LEGAL 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

Who is going to fund this referral?*

If the service is to be paid for by a local authority, please give details including the team name and address*

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

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

GP name and address details*

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*