10 - Older Neighbour Referral form
Default Organisation Owner Id
Default Contact Owner Id
Default Phone a Friend Owner Id
Default Digital Social Club Owner Id
Winter Wellbeing Notification User Id
Older Neighbour Referral Notification User Id
Default Letter/Postal Activity Packs Owner Id
A professional referring an older person
Referring a friend, family member or contact
Professional or Friend
Please tell us the reason for this referral
Referral to programme activities
Please provide us with some information in relation to the reason for this referral
Every month we send our social clubs programme and information about our activities to our community partners. Would you like to be added to that mailing list?
How did you hear about us?
Is this referral for our virtual, phone-in and in-person Social Clubs?
Our virtual, phone-in and in-person Social Clubs are free group activities ranging from discos to poetry workshops, indoor gardening tips to cook-along clubs and seated Yoga sessions. We host these clubs in person, over the phone and virtually via Zoom. To join our Phone-in Clubs, all that's required is a landline or mobile (both of which are free to call in on). And to join our Zoom Clubs, you'll need access to the internet via a smartphone, laptop or tablet.
Is this referral for tech support to help with using Zoom to access our online group activities?
Where possible, we’re aiming to offer over the phone support to help our older neighbours to access our online activities through Zoom. So if you have access to the internet on a smartphone or laptop, but aren’t sure how to video call - we can help! Please note that unfortunately, we’re not able to provide any tech equipment, tech advice or support with getting connected to the internet - as sadly we’re not tech experts.
Is this referral for our Love Your Neighbour programme?
Love Your Neighbour is a friendship matching programme. It introduces younger and older neighbours living across Camden and Islington to spend time together one-to-one, either over the phone, in person or a mixture of both.
Is this referral for our Winter Wellbeing programme?
Winter Wellbeing is our seasonal programme which actively helps older neighbours to stay warm, active and connected.
Is this referral for Postal Activity Packs?
Postal Activity Packs are activities that older neighbours can do at home, delivered to their door for free.
Is this referral for Practical Support?
Although we’re not able to directly provide practical support ourselves, we are able to signpost older neighbours to our local and national partners to help them access the right help.
Please confirm that you have received the consent of the older neighbour to make this referral
Older Neighbour details
Date of birth (dd/mm/yyyy)
We only take referrals for people
aged 65 and over
If you don't know their email address or they don't have one, please leave blank.
What is the best way to contact this neighbour?
information about contacting this individual, please add this to the
comments box at the end of this form.
Have you met this neighbour in person?
This information can really help during welcome calls to new neighbours.
Please share any
medical information that you know of. Please note that we are not able to take referrals for people living with dementia or severe, unmanaged, mental health conditions.
Does this person have any disabilities or accessibility needs?
Have you ever visited this neighbour at their home?