ALONE Self Referral Form

Key Information:

First Name

Last Name

Date of Birth

please note that ALONE is a charity that supports people aged 60+

Gender

Female	Male	Transgender
Non-binary	Undeclared / Not Specified

House Number and Street Address

Area

The area where the person lives such as Kilmainham, Dundalk, Kilkenny City, Buncrana.

County / Postcode

Eircode

To find the EIRCODE, please visit EIRCODE FINDER

Main Contact Number

Other Contact Number (e.g. landline)

Your Email

Emergency Contact and their Contact Details

Please include name, contact details and relationship.

How did you hear about ALONE?

How can ALONE support?

Please select one or more of our services below:

Housing

Daily Living and Personal Care

Physical Health and Mobility

Emotional and Mental Health

Loneliness and Befriending

Financial Issues

Safeguarding

Technology Support

Why is ALONE's support needed?

What is are the main reasons ALONE's support is needed? Is it loneliness, physical health, dementia, mental health, housing difficulties, or other?

Does anyone else live in the home? If yes, please give details

Yes

If yes, please give details

Is there any other important information ALONE should know about?

Professional Supporter Details

Please use this section to provide us with the details of a medical or social professional. We may need to contact this person in advance of our first visit. Please confirm below if we have the permission to do so.

Can we contact this person?

Full name

Phone number

Job title or relationship

Organisation they work for

Consent:

In order to process the referral, you must confirm that consent has been received and the date that it was received:

I am happy for ALONE to store my contact details:

Yes

Please read ALONE's privacy statement

Date Submitted

Please note:
When you press the submit button below you will see a summary of your form.

You must press the confirm button on the summary page for the referral to be completed.

Contact Information