Compassionate Neighbours Referral Form

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Compassionate Neighbours is free, community-led support for anyone who is lonely and/or socially isolated and is nearing the end of life through age or illness. It is delivered by Garden House Hospice Care in North Herts.

Following referral, the person will be contacted and visited to assess their suitability and needs. If they consent to receiving support from a Compassionate Neighbour, we will then seek to match them with a trained and supported person who will visit them regularly.

Referrer Details

Are you referring individually or on behalf of an organisation?

If you are referring as an individual, is it on behalf of somebody else or for yourself?

Referring Organisation Name:

If your Organisation is not mentioned on this list, then please select "Other" and specify the name of your organisation

Please provide the Organisation Name:

Your First Name:

Your Last Name:

Your Phone Number:

No spaces allowed

Your Email:

Relationship:

eg. Friend, Family Member

Details of the person who would like support

First Name:

Last Name:

Telephone Number:

No spaces allowed

Mobile:

No spaces allowed

Gender:

Date of Birth:

Enter date as DD/MM/YYYY or use the calendar

If Other, please specify:

Please note: we currently have a waiting list of 2 months in the Stevenage area.

Address:

City:

Postcode:

Please enter postcode with a space (eg SG6 1QU)

Email Address:

Permission/Consent

Has the person agreed to be referred to this project?

Is the person willing to be contacted by phone?

Is the person willing to be contacted by post

Is the person willing to be contacted by email

Additional Details

Preferred Language:

If Other, please specify Language

Will a translator be required for a home visit?

Do they have pets?

What is the access like to their property?

Are there any health or behaviour factors that we should be aware of prior to a home visit?

Reason for Referral

What sort of help/support is required?

Additional information?

Next of Kin details

First Name:

Last Name:

Relationship:

Telephone Number:

No spaces allowed

Other Information:

Referral Date:

Enter date as DD/MM/YYYY or use the calendar

Please Note:

The Referrer will only be notified should a suitable match be unsuccessful or the person does not meet our criteria.

Thank you for your referral. If there is anything else you would like to discuss, please contact the Compassionate Neighbours Team.

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Contact Information