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
RHA Area
Please select...
HSE West and North West
HSE Dublin and North East
HSE Dublin and Midlands
HSE Midwest
HSE Dublin and South East
HSE South West
CHN Area
Please select...
Ballyfermot and Palmerstown
Clondalkin
Drimnagh, Crumlin, and Harold's Cross
East Kildare and Blessington
East Offaly and North Laois
East Westmeath
Longford and Central Westmeath
Lucan
Newcastle, Citywest and Saggart
Northeast Kildare
Northwest Kildare
Offaly
Rathfarnham, Knocklyon and Ballyboden
Rathmines, Terenure and Templeogue
South Dublin Inner City
South Kildare and West Wicklow
South Laois
Tallaght and Firhouse
West and Central Kildare
West Westmeath and Northwest Offaly
Balbriggan Area Network
Ballymun Area Network
Blakestown Area Network
Blanchardstown Area Network
Cabra Area Network
Cavan
Central Meath
Clontarf Area Network
Coastal Area Network
Coolock Area Network
East Meath
Finglas Area Network
Kilbarrack Area Network
Monaghan
North Inner City Area Network
North Louth
North Meath and Ardee
South Louth and Bettystown
Southwest Meath
Swords Area Network
Ballinteer, Stepaside and Kiltiernan
Central Kilkenny and South Carlow
Central Tipperary
Central Wexford
Donnybrook, Ranelagh and Ringsend
Dun Laoghaire, Dalkey and Loughlinstown
Foxrock, Carrickmines and Shankill
Milltown, Churchtown and Dundrum
North Carlow
North Kilkenny and City
North Wexford
Northeast Wicklow
South Tipperary and North Waterford
Southeast Wexford
Southeast Wicklow
Southwest Wexford
Stillorgan, Booterstown and Monkstown
Waterford City
West Waterford and Tramore
East Clare
East Limerick and Ballina
North Limerick City
North Tipperary
South Limerick
South Limerick City
West Clare
West Limerick
Ballincollig, Bishopstown, Macroom
Bandon, Kinsale and Carrigaline
Blarney and North Cork City
Central Cork
Douglas, Blackrock, Mahon
East Central Cork
East Cork City
Mallow, Charleville, Newmarket, Kanturk, Millstreet
North Kerry
Northeast Cork
South Cork City
South Kerry
West Cork
West Kerry
Central Galway and East Galway City
Donegal East
Donegal North
Donegal South and West
East Galway and South Roscommon
East Mayo
Inishowen
Leitrim and West Cavan
North Mayo
North Roscommon and North East Galway
Sligo South Donegal
Tuam, Athenry, and Loughrea
West Galway
West Galway City
West Mayo
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
RHA Area
Please select...
HSE Dublin and Midlands
HSE Dublin and North East
HSE Dublin and South East
HSE Midwest
HSE South West
HSE West and North West
CHN Area
Please select...
Ballyfermot and Palmerstown
Clondalkin
Drimnagh, Crumlin, and Harold's Cross
East Kildare and Blessington
East Offaly and North Laois
East Westmeath
Longford and Central Westmeath
Lucan
Newcastle, Citywest and Saggart
Northeast Kildare
Northwest Kildare
Offaly
Rathfarnham, Knocklyon and Ballyboden
Rathmines, Terenure and Templeogue
South Dublin Inner City
South Kildare and West Wicklow
South Laois
Tallaght and Firhouse
West and Central Kildare
West Westmeath and Northwest Offaly
Balbriggan Area Network
Ballymun Area Network
Blakestown Area Network
Blanchardstown Area Network
Cabra Area Network
Cavan
Central Meath
Clontarf Area Network
Coastal Area Network
Coolock Area Network
East Meath
Finglas Area Network
Kilbarrack Area Network
Monaghan
North Inner City Area Network
North Louth
North Meath and Ardee
South Louth and Bettystown
Southwest Meath
Swords Area Network
Ballinteer, Stepaside and Kiltiernan
Central Kilkenny and South Carlow
Central Tipperary
Central Wexford
Donnybrook, Ranelagh and Ringsend
Dun Laoghaire, Dalkey and Loughlinstown
Foxrock, Carrickmines and Shankill
Milltown, Churchtown and Dundrum
North Carlow
North Kilkenny and City
North Wexford
Northeast Wicklow
South Tipperary and North Waterford
Southeast Wexford
Southeast Wicklow
Southwest Wexford
Stillorgan, Booterstown and Monkstown
Waterford City
West Waterford and Tramore
East Clare
East Limerick and Ballina
North Limerick City
North Tipperary
South Limerick
South Limerick City
West Clare
West Limerick
Ballincollig, Bishopstown, Macroom
Bandon, Kinsale and Carrigaline
Blarney and North Cork City
Central Cork
Douglas, Blackrock, Mahon
East Central Cork
East Cork City
Mallow, Charleville, Newmarket, Kanturk, Millstreet
North Kerry
Northeast Cork
South Cork City
South Kerry
West Cork
West Kerry
Central Galway and East Galway City
Donegal East
Donegal North
Donegal South and West
East Galway and South Roscommon
East Mayo
Inishowen
Leitrim and West Cavan
North Mayo
North Roscommon and North East Galway
Sligo South Donegal
Tuam, Athenry, and Loughrea
West Galway
West Galway City
West Mayo
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