Referrals – LGBTFriending

Who is completing this form? *

Referral Organisation

Referrer Contact Name

First

Last

Referrer Phone

Referrer Email

Your relationship to the individual referred

Has the individual given their consent/expressed an interest in the Befriending Service?

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Email *

Preferred method of contact *

Please tick all that apply

I am LGBT+, am over 50 and am isolated and have Limited Social Connections
I am LGBT+, housebound (no age restrictions) and have Limited Social Connections
I am LGBT+, over the age of 18 and during the COVID pandemic I am feeling isolated would like the chance to hear another human voice at the end of a phone

Any special requirements that might be relevant

Please provide a brief outline of present circumstances *

What benefits do you think would be gained from Befriending? *

What type of Befriending service would be most appropriate? *

Please give a brief description of the type of Befriender preferred (i,e. male/female; age; interests etc) *

Please tell us about hobbies and interests (this helps us match with a Befriender) *

Please provide any other additional information that might prove helpful in making a successful match with a Befriender *