Referral For A Person That I know

I would like to refer a person that I know

Please fill out your own details here:

Your First name

Your Surname

Your Relationship to this person

Your Email address

Your Contact number

Your County / Postcode

How did you hear about ALONE?

Consent:

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

Does the older person know about the referral, and have they agreed to it?

Please read ALONE's privacy statement

Key Information about the Older Person:

Please use the key information section below to fill in the information about the person you are referring.

First Name

Last Name

Date of Birth

Please note that the person should be over 60+. Date format DD/MM/YYYY

Gender

House number and street

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 Phone Number

Additional Phone number (e.g., Landline)

Emergency Contact and their Contact Details

Please include name, contact details and relationship.

Is there any reason this person may be unable to communicate on the phone with ALONE staff

Yes

If Yes, please give reason:

Please provide some additional information about this referral:

Please provide any other relevant information about the older person, including risks to staff(e.g., substance abuse, pets)

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

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