Referral from a Professional
I would like to
refer an older person I work with
Please fill out your own details here:
Your First name
Your Surname
Your Email address
Your Contact number
Profession
Please select...
Age Friendly Coordinator
Community Support Worker
General Practitioner
Housing Officer
Liaison Officer
Occupational Therapist
Other
Physiotherapist
Public Health Nurse
Social Worker
Staff nurse
If other, please specify
Organization
Please choose the name of the hospital, GP ect.
you work with
Which MRH Unit or Ward do you work on?
Organization Setting
Please select...
Hospital
General Practice
Primary Care setting
Community based service
Age Friendly Healthy Homes
Other
If this is a hospital referral which area
do you work in?
Please select...
ICPOP
FIT
ED
Other
If "Other" what area do you work in?
CHO Area
Please select...
CHO 1
CHO 2
CHO 3
CHO 4
CHO 5
CHO 6
CHO 7
CHO 8
CHO 9
Not Known
CHN Area
Please select...
Inishowen (CHN Learning Site)
East Donegal
North Central Donegal
Cavan
Monaghan
Leitrim / West Cavan
Sligo / North Leitrim / Bundoran
West Donegal
North Roscommon/North East Galway
Central Galway / East Galway City
West Galway
West Galway City
Tuam / Athenry / Loughrey (CHN Learning Site)
East Galway / South Roscommon
East Mayo
North Mayo
West Mayo
West Clare
North Tipperary
East Clare
West Limerick
East Limerick / Ballina
South Limerick City (CHN Learning Site)
South Limerick
North Limerick City
North Kerry
West Kerry
South Kerry
Northwest Cork
Northeast Cork
East Central Cork
East Cork City
Central Cork
Blarney / North Cork City
West Cork
Southeast Cork City
West Central Cork
Bandon / Carrigaline / Kinsale (CHN Learning Site)
South Cork City
North Kilkenny / Kilkenny City (CHN Learning Site)
Central Kilkenny / South Carlow
North Carlow
Waterford City
West Waterford / Tramore
South Tipperary / North Waterford
Central Tipperary
North Wexford
Southeast Wexford
Southwest Wexford
Southeast Wicklow (CHN Learning Site)
Northeast Wicklow
Balinteer / Stepaside / Kiltiernan
Foxrock / Carrickmines / Shankhill
Milltown / Churchtown / Dundrum
Dun Laoghaire / Dalkey / Loughlinstown
Stillorgan / Booterstown / Monkstown
Donnybrook / Ranelagh / Ringsend
Rathmines / Terenure / Templeogue
Driminagh / Crumlin / Harolds Cross
South Dublin Inner City
Ballyfermot / Palmerstown (CHN Learning Site)
Lucan
Northeast Kildare
Rathfarnham / Knocklyon / Ballyboden
Tallaght / Firhouse
Newcastle / Citywest / Saggart
Clondalkin
East Kildare / Blessington
West / Central Kildare
South Kildare / West Wicklow
Northwest Kildare
East Westmeath (CHN Learing Site)
Longford and Central Westmeath
West Westmeath / Northwest Offaly
Offaly
South Laois
East Offaly / North Laois
North Louth
South Louth / Bettystown
Central Meath
North Meath / Ardee
South Westmeath
East Meath
Northwest Dublin Inner City
Northeast Dublin Inner City
Drumcondra / Doneycarney / Clontarf
Harmonstown / Raheny / Donaghmede
Beaumont / Coolock / Darndale
Poppintree / Ballymun / Santry (CHN Learning Site)
Swords / Malahide
Balbriggan / Skerries / Lusk
Howth / Portmarnock
Clonee / Mulhuddart
Castleknock / Blanchardstown
St. Margarets / Finglas / Galsnevin
Not Known
Your County / Postcode
Please select...
Abroad
Co. Antrim
Co. Armagh
Co. Carlow
Co. Cavan
Co. Clare
Co. Cork
Co. Derry
Co. Donegal
Co. Down
Co. Dublin
Co. Fermanagh
Co. Galway
Co. Kerry
Co. Kildare
Co. Kilkenny
Co. Laois
Co. Leitrim
Co. Limerick
Co. Longford
Co. Louth
Co. Mayo
Co. Meath
Co. Monaghan
Co. Offaly
Co. Roscommon
Co. Sligo
Co. Tipperary
Co. Tyrone
Co. Waterford
Co. Westmeath
Co. Wexford
Co. Wicklow
Dublin 1
Dublin 2
Dublin 3
Dublin 4
Dublin 5
Dublin 6
Dublin 6w
Dublin 7
Dublin 8
Dublin 9
Dublin 10
Dublin 11
Dublin 12
Dublin 13
Dublin 14
Dublin 15
Dublin 16
Dublin 17
Dublin 18
Dublin 20
Dublin 22
Dublin 24
North County Dublin
South County Dublin
How did you hear about ALONE?
Please select...
Advertisement - other media
ALONE Website
External Organisation/Colleague
From a friend/family member
Media (local/national)
Social Media
Other
Do you consent to ALONE storing your details? We may need to contact you about this referral.
Yes
No
Please read ALONE's privacy statement
Consent
In order to process the referral, you must confirm that consent has been received from the person you are referring and the date that it was received:
Is the Older Person aware this referral
is being made?
Yes
No
Has consent been received for this referral?
Yes
No
Please read ALONE's privacy statement
Date Consent Received
Key Information:
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
x
Gender
Please select...
Female
Male
Transgender
Non-binary
Prefer not to say
Other
House number and street
Area
The area where the person lives such as Kilmainham, Dundalk, Kilkenny City, Buncrana.
x
County / Postcode
Please select...
Co. Antrim
Co. Armagh
Co. Carlow
Co. Cavan
Co. Clare
Co. Cork
Co. Derry
Co. Donegal
Co. Down
Co. Dublin
Co. Fermanagh
Co. Galway
Co. Kerry
Co. Kildare
Co. Kilkenny
Co. Laois
Co. Leitrim
Co. Limerick
Co. Longford
Co. Louth
Co. Mayo
Co. Meath
Co. Monaghan
Co. Offaly
Co. Roscommon
Co. Sligo
Co. Tipperary
Co. Tyrone
Co. Waterford
Co. Westmeath
Co. Wexford
Co. Wicklow
Dublin 1
Dublin 2
Dublin 3
Dublin 4
Dublin 5
Dublin 6
Dublin 6w
Dublin 7
Dublin 8
Dublin 9
Dublin 10
Dublin 11
Dublin 12
Dublin 13
Dublin 14
Dublin 15
Dublin 16
Dublin 17
Dublin 18
Dublin 20
Dublin 22
Dublin 24
North County Dublin
South County Dublin
Eircode
To find the EIRCODE, please visit
EIRCODE FINDER
CHO Area
Please select...
CHO 1
CHO 2
CHO 3
CHO 4
CHO 5
CHO 6
CHO 7
CHO 8
CHO 9
Not Known
CHN Area
Please select...
Inishowen (CHN Learning Site)
East Donegal
North Central Donegal
Cavan
Monaghan
Leitrim / West Cavan
Sligo / North Leitrim / Buncrana
West Donegal
North Roscommon/ North East Galway
Central Galway / East Galway City
West Galway
West Galway City
Tuam / Athenry / Loughrea (CHN Learning Site)
East Galway / South Roscommon
East Mayo
North Mayo
West Mayo
West Clare
North Tipperary
East Clare
West Limerick
East Limerick / Ballina
South Limerick City (CHN Learning Site)
South Limerick
North Limerick City
North Kerry
West Kerry
South Kerry
Northwest Cork
Northeast Cork
East Central Cork
East Cork City
Central Cork
Blarney / North Cork City
West Cork
Southeast Cork City
West Central Cork
Bandon / Carrigaline / Kinsale (CHN Learning Site)
South Cork City
North Kilkenny / Kilkenny City (CHN Learning Site)
Central Kilkenny / South Carlow
North Carlow
Waterford City
West Waterford / Tramore
South Tipperary / North Waterford
Central Tipperary
North Wexford
Southeast Wexford
Southwest Wexford
Southeast Wicklow (CHN Learning Site)
Northeast Wicklow
Balinteer / Stepaside / Kiltiernan
Foxrock / Carrickmines / Shankhill
Milltown / Churchtown / Dundrum
Dun Laoghaire / Dalkey / Loughlinstown
Stillorgan / Booterstown / Monkstown
Donnybrook / Ranelagh / Ringsend
Rathmines / Terenure / Templeogue
Driminagh / Crumlin / Harolds Cross
South Dublin Inner City
Ballyfermot / Palmerstown (CHN Learning Site)
Lucan
Northeast Kildare
Rathfarnham / Knocklyon / Ballyboden
Tallaght / Firhouse
Newcastle / Citywest / Saggart
Clondalkin
East Kildare / Blessington
West / Central Kildare
South Kildare / West Wicklow
Northwest Kildare
East Westmeath (CHN Learing Site)
Longford and Central Westmeath
West Westmeath / Northwest Offaly
Offaly
South Laois
East Offaly / North Laois
North Louth
South Louth / Bettystown
Central Meath
North Meath / Ardee
South Westmeath
East Meath
Northwest Dublin Inner City
Northeast Dublin Inner City
Drumcondra / Doneycarney / Clontarf
Harmonstown / Raheny / Donaghmede
Beaumont / Coolock / Darndale
Poppintree / Ballymun / Santry (CHN Learning Site)
Swords / Malahide
Balbriggan / Skerries / Lusk
Howth / Portmarnock
Clonee / Mulhuddart
Castleknock / Blanchardstown
St. Margarets / Finglas / Galsnevin
Not Known
Primary Contact Number
Secondary Contact Number
Additional Phone number (e.g., Landline)
Next of Kin Name / Relationship / Emergency Contact Number
Please include name, contact details and relationship.
x
GP Details
(Contact Number / Practice Name /
Address)
Is there any reason this person may be unable to communicate on the phone with ALONE staff
Yes
No
If Yes, please give reason:
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
Are you aware of any risks or potential risks to our staff visiting this person's home?
Yes
No
Are you aware of any risks or potential risks to our staff visiting this person's home?
x
If Yes, please give detail
Are you aware of any risks or potential risks to our staff visiting this person's home?
x
Does the person being referred live alone?
Please select...
Yes
No
Please outline the reasons that ALONE’s support is needed e.g. Loneliness, physical/mental health issues, housing difficulties or other.
Also include any relevant information you feel is important such as important relationships, other services you are referring this older person to and services they are already engaged with.
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.
You will receive a confirmation email once the referral has been received by ALONE.
Contact Information