Make a Referral

Make an online referral

If you wish to refer yourself or someone you know to our service please fill out and submit the form below and we can take the first steps by contacting the client for an initial assessment visit.

To be eligible for our services, clients need to:

Be a Tower Hamlets resident
Experience loneliness and social isolation
Be aged 55 or over
Have no history of severe mental illness or history of addiction

Please note that during the Covid – 19 crisis we re no longer visiting clients at home, but are accepting referrals for telephone befriending.

For help with this form please call us on: 020 8983 7979

About yourself (the referrer)

Your Details

Referrer Name

This is a required field

Referrer Telephone Number

Valid phone number required

Address Line 1

This is a required field

Address Line 2

Town

This is a required field

Postcode

This is a required field

Referrer Email

Valid email required

Referrer Relationship to the Client

This is a required field

Referrer Organisation

This is a required field

Please confirm that you are going to still be involved with the client for the next 6 weeks

This is a required field

If not, Please provide another contact

This is a required field

The Referral

Does the client understand and agree to this referral?

This is a required field

Why are you making this referral to THFN? Please give specific reasons and as much background as possible.

This is a required field

About the person you are referring (the 'client')

Client Details

Name

This is a required field

A different name/nickname, if preferred?

Address Line 1

This is a required field

Address Line 2

Town

This is a required field

Postcode

This is a required field

Telephone Number

Valid phone number required

Valid email required

Date of Birth (Service available for over 55s only)

Required fields

Gender

This is a required field

Ethnicity

This is a required field

Languages Spoken

This is a required field

Emergency Contact/NOK Name

This is a required field

Emergency Contact/NOK Email

Valid email required

Does this client want a Telephone Befriender, Face to Face Befriender, Either or Both?

Telephone
Face to Face
Either
Both

Living Arrangements

Client's current accommodation type?

Does the client live alone?

This is a required field

Who does the client live with?

This is a required field

Are there any contact/access issues? (e.g. no phone, cannot get to door, key safe, etc)

This is a required field

Health and safety issues (e.g excessive clutter, falls risk, etc)

This is a required field

Are there any other issues you think that we need to take into consideration? (e.g. aggressive animals, smoking, problems with neighbours, money, etc)

This is a required field

Give us some information about the client's situation

Current access to other services

Does client have a social care Personal Budget?

This is a required field

Client has a Care Plan or Personal Support Plan?

This is a required field

Does this plan cover befriending or escorting?

This is a required field

How would the service provided by THFN link to the plan?

This is a required field

What services does the client currently receive?

Statutory Services (Including help, carers, Meals on wheels)

This is a required field

How often does the client receive statutory services?

This is a required field

Carer Agency

This is a required field

Agency Name

This is a required field

Agency Telephone Number

Valid phone number required

Day Centres/Clubs

This is a required field

Centre Name/Location

This is a required field

Frequency of visits

This is a required field

Other (e.g. CMHT, Falls Management etc)

This is a required field

Details

This is a required field

Current social network/interests

Provide details of any regular contact with visitors, family, agencies, etc

Does the client have any special factors to consider (e.g. recent bereavement, religious/spiritual needs)

What are the client's interests and/or hobbies?

Is there any other information you wish to provide that you think may be useful?

Please provide medical details for the client

About the client's health

Doctor's Name

This is a required field

Doctor's Telephone

Valid phone number required

Address Line 1

This is a required field

Address Line 2

Town

This is a required field

Postcode

This is a required field

Doctor's Email

Valid email required

Does the client have any of the following health issues?

Dietary Issues

This is a required field

Details

This is a required field

Sleeping issues

This is a required field

Details

This is a required field

Mobility issues

This is a required field

Details

This is a required field

Physical impairment

This is a required field

Details

This is a required field

Hearing Impairment

This is a required field

Details

This is a required field

Vision Impairment

This is a required field

Details

This is a required field

History of falls

This is a required field

Details

This is a required field

Alzheimers

This is a required field

Details

This is a required field

Dementia

This is a required field

Details

This is a required field

Depression

This is a required field

Details

This is a required field

Diabetes

This is a required field

Details

This is a required field

Stroke

This is a required field

Details

This is a required field

Heart condition

This is a required field

Details

This is a required field

Other long term conditions

This is a required field

Details

This is a required field

Does the client have a history of serious mental health issues?

This is a required field

Details

This is a required field

Vaccination

Has the client had a Covid-19 vaccination?

This is a required field

Has the client had a booster jab or any other vaccination (flu jab etc.) in the last 12 months?

This is a required field

Details
(type of vaccination and date)

This is a required field

Arranging an assessment - please provide these final details

Further contact information

Can we contact the client directly to arrange an assessment?
(Please note we require both a telephone number and an email address before an assessment can take place, and for the next of kin to be notified)

This is a required field

Representative Details

Representative's Name

This is a required field

Relationship to the client?

This is a required field

Representative's Email

Valid email required

Representative's Telephone Number

Valid phone number required

Address Line 1

This is a required field

Address Line 2

Town

This is a required field

Postcode

This is a required field

Please confirm that this person has been informed of the referral

This is a required field

Do they have a mobile phone and/or access to the internet?

Are there any medical impairments that will hinder the client from speaking on the phone?

Contact details for people involved with the client

Social Worker Name

Social Worker Telephone

Valid phone number required

Warden Name

Warden Telephone

Valid phone number required

District Nurse Name

District Nurse Telephone

Valid phone number required

Any other contact details