Befriending Self-Referral Form

Your Name

Do you want (At assessment we might decide you are better suited to a different option than selected.) (required)

Face-to-Face Befriending Only for people living in LondonTelephone Befriending For anyone living in the UK (including the Out Together Telefriending Partnership in West Yorkshire)Happy with either

How did you hear about the Befriending Service?

Address (please specify which borough) (required)

Telephone number (required)

Email address

Date of birth (required)

Gender (including pronouns) (required)

Sexuality (required)

Ethnicity

What is your religion/belief/faith?

If other, please specify:

Do you have any disabilities? (required)

Preferred language spoken: (required)

When would be the best days/time to receive a befriending call/visit? (required)

Reason for wanting to join the Befriending service (required)

Current social contacts (e.g. lunch clubs, social groups, friends/family… (required)

Who can we contact for you in an emergency or if we don’t hear from you for a few weeks? (required)

Do you receive any care? (It would be helpful if you could also list your GP, Social Worker or Care Worker if you have one) (required)