Visiting Service – Client Self Referral Form

Before making a referral please note all four of these criteria have been met:

1. Is the person in question over or close to 65?
2. Is the person at risk of social isolation due to having no or very few visitors?
3. Is the person able to contribute to a mutually beneficial friendship/relationship?
4. Has the service been explained to the person, and have they given their permission to be referred to Age Concern?

Visiting Service – Client Self Referral Form

Client Details(Required)
Address
MM slash DD slash YYYY
Ethnicity (tick any that apply)
Are you Living Alone?
Does live in a rest home/residential care facility?

Next of Kin or Emergency Contact Information

Identified hazards (Please tick any hazards that may pose a risk to Visiting Service Workers , and provide details)
Referrer's details (if different to the person who is self-referring)
Organisation