Referral from a Relative

I would like to refer a Relative

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?

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 older person and the date that it was received:

Has consent been received for this referral

Please read ALONE's privacy statement

Date Consent Received

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

Primary Contact Number

Secondary Contact Number

Emergency Contact Name and Number

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

No

If Yes, please give reason: (goes to Consult b4 contact box)

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

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.

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?

Yes

No

If yes, please give details

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?

If Yes, please give detail

Are you aware of any risks or potential risks to our staff visiting this person's home?

Contact Information