10 - Older Neighbour Referral form
SC-LYN-WW
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
Your details
I am
A professional referring an older person
Referring a friend, family member or contact
Professional or Friend
First name
Last name
Organisation
Telephone number
Email address
Please tell us the reason for this referral
Emotional support
Isolation
Loneliness
Referral to programme activities
Social interaction
Other
Please provide us with some information in relation to the reason for this referral
As a guide we're looking for 100-200 words to give context to your referral.
Every month we send our social club programme and information about our activities to our community partners. Would you like to be added to that mailing list?
Yes
How did you hear about us?
Friend
Family
Social media
Google search
Press/radio
Local authority
Cares outreach
Health Professional
Community group
Neighbour
Age UK
Other
How heard other
Is this referral for our virtual, phone-in and in-person Social Clubs?
Yes
No
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?
Yes
No
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?
Yes
No
Love Your Neighbour is a friendship matching programme. It introduces younger and older neighbours living across the city of Liverpool, to spend time together one-to-one, either over the phone, in person or a mixture of both.
Is this referral for Postal Activity Packs?
Yes
No
Postal Activity Packs are activities that older neighbours can do at home, delivered to their door for free.
Is this referral for Practical Support?
Yes
No
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
Yes
Older Neighbour details
First name
Last name
Date of birth (dd/mm/yyyy)
We only take referrals for people aged 65 and over
Email address
If you don't know their email address or they don't have one, please leave blank.
Address
Please note that for the Love Your Neighbour programme we are not able to take referrals for people who live outside of the City of Liverpool.
Postcode
Telephone number
Medical history
Please note that we are not able to take referrals for people living with dementia or severe unmanaged mental health conditions.
Living arrangements
Further information