Volunteer Befriending Service Referral Befriending Service Referral Form Step 1 of 5 20% Please note:Befriending volunteers do not provide personal or domestic care (i.e. washing or getting dressed). If personal care is required, please contact Gateshead Council’s Adult Social Care Department. Please contact us for more information about the befriending service at Caregivers Connected Gateshead if you require more information.Please confirm if personal care is required(Required) Personal Care is required Personal Care is NOT required Please confirm that personal care has been arranged with Adult Social Care(Required) Personal care HAS been arranged with Adult Social Care Personal care has NOT been arranged with Adult Social Care ⚠️ Unfortunately, our volunteer befriending service cannot support a befriendee who has personal care needs which are not supported by Adult Social Care. Contact Gateshead Adult Social Care to find out more about receiving support with personal care needs. Referrer DetailsReferrer Name(Required) First Name Last Name Referrer Job RoleReferrer Phone Number(Required)Referrer Email Address(Required) Accessing Befriending ServiceHas the carer of the befriendee received support from us, Caregivers Connected Gateshead, before?(Required)i.e. Are they registered as a carer with us? Yes No ⚠️ Our volunteer befriending service cannot support anyone who is not firstly registered as a caregiver with us. Please complete our Online External Referral Form before making a referral to our befriending service form.Caregiver Name First Name Last Name Has GDPR consent been given by the caregiver for this referral to be made?(Required) Yes No Who is the person to be befriended(Required) The cared for The caregiver Details of the Befriending ServicePlease select the frequency of the sessionsThis service is delivered by volunteers so we cannot guarantee a match. Please select at least one morning or afternoon slot. Weekly Fortnightly Monthly What is the preferred duration of the session? 2 hours 3 hours 4 hours If you have a specific start time, please let us know here.Monday Morning Afternoon Evening Tuesday Morning Afternoon Evening Wednesday Morning Afternoon Evening Thursday Morning Afternoon Evening Friday Morning Afternoon Evening Saturday Morning Preferred gender of befrienderWhat likes, hobbies and interests does the befriendee have?What would the client like to do during their session? SafeguardingAre the family involved with any safeguarding procedures?(Required) Yes No If yes, please provide details below.Risk AssessmentAre there any risks to our workers that we need to be aware of when visiting or contacting the family / household?(Required) Yes No If yes, please provide details below.Key InformationPlease let us know any important and relevant information which may have an impact on the volunteer befriender.Please list any medical conditions the befriendee has.Does the befriendee have any specific language or communication requirements?(Required)Does the befriendee have any mobility issues?(Required)Does the household have any pets?(Required)Please let us know about access to the propertyi.e. parking arrangementsPlease let us know any other information that may be relevant to our volunteer befriending service ConsentSuitability and Consent(Required) I agree.The person I am referring is suitable for the volunteer befriending scheme and has consented to this referral being made.Data Privacy Consent(Required) I agree to the privacy policy.By submitting this form I agree to sharing my information with Carers Federation according to the Carers Federation privacy policy.Your Data Please tick this box if you would like to receive a copy of your response via email when submitted.
