Befriending Project

REFERRAL FORM

Befriending Criteria - Guidelines for Referrals

The issues people have to deal with in their lives can make them feel isolated and/or vulnerable. A befriending relationship can help people tackle these issues.

It is important to remember that Befrienders are not advocates/ carers/advisers/personal assistants/shoppers/counsellors/DIY helpers etc. But they are part of the intervention to increase people’s access and involvement in their communities.

Please answer the following questions as honestly as you can, and return the completed form to the Project Co-ordinator. We will then let you know whether or not the person being referred is eligible for our service.

Moving On’ Project – Eligibility Criteria / YES / NO
Is the person 50 years of age (or close to reaching 50)?
Does the person have an identified mental health issue or learning disability?
Does the person live on his/her own?
Does the person live with a dependent that limits his/her opportunities to access the local community?
If the person lives with a dependent, is that dependent considered ‘vulnerable’?
Does the person have very little contact with family members? (E.g. Once or twice a year.)
Does the person live with a family member but still feel isolated?
If Yes, please say why in box below
Does the person access the community less than 3 times a week?
Does the person lack confidence to access the community on his/her own?
Is the person able to give consent to having a Befriender?
Does the person have any serious predictable or unpredictable behavioural problems that would put a volunteer at risk?
If Yes, can you say what they are below:
Does the person have mobility difficulties?
If Yes , please provide details below

AGENCY REFERRAL FORM

PERSONAL DETAILS (Person being referred)
Name
Mr/Ms/Miss/Mrs
Address
(Line 1)
(Line 2)
Post Code
Telephone Number
E-Mail Address
Date of Birth
Does the beneficiary have a mental health disorder? / Yes / No
Does the beneficiary have a learning disability? / Yes / No
REFERRING AGENCY If NOT A SELF REFFERAL (e.g. Social Services, GP)
Name of Agency
Department
(If Applicable)
Address of Agency
Post Code
Contact Telephone Number(s)
Email address of Referrer
Name and Job Title of Referrer
Length and of time involved with beneficiary / ………. Years……..months
Frequency of contact / ☐ Regular ☐ Occasional ☐ Rarely
Please provide details of how the Befriending Project can assist this person?
Any information provided will be treated in accordance with the Confidentiality Policies of Mental Health Matters Wales and Bridgend People First
In the unlikely event of an emergency please provide GP details:
Name of GP: / GP Tel. No.:
In the unlikely event of an emergency who would you like us to contact?
Name:
Relationship:
Address:
Tel No:
Has the person being referred consented to this referral? / Yes / No
If no, please say why:
Beneficiary (or his/her representative’s signature): / Date:
Referrers signature: / Date:
Please send completed form to / Befriending Coordinator/Facilitator Mental Health Matters Wales
63 Nolton Street
Bridgend
CF31 3AE
Tel number: 01656 767045/679884
Email:

Referral Risk Assessment – RA1

This form is to be completed by professionals who have knowledge of individuals referred to the Befriending project. It is essential that all questions are answered fully and the form is signed at the bottom of the page.

The information provided on this document will remain confidential and be used in assessing the eligibility of the individual referred to the Moving On over 50’s befriending project in partnership with Mental Health Matters Wales and Bridgend People First.

Mental Health Matters Wales and Bridgend People First comply with the Data Protection Act that gives individuals the right of access to their personal information.

Name of Beneficiary: / Date of Birth:
Do you pose a risk to yourself?
If Yes, what is the nature and likelihood of this risk? / Yes / No
Do you pose a risk to others?
If Yes, what is the nature and likelihood of this risk? / Yes / No
Are you at risk from any third party (e.g. someone you live with, or someone else you know)?
If Yes, who is this person and what is the nature and likelihood of this risk? / Yes / No
Are others (e.g. professionals) at risk from any third party in your life?
If Yes, who is this person and what is the nature and likelihood of this risk? / Yes / No
Are there any other risks relating to you (e.g. family, children, location of your home)?
If Yes, what is the nature and likelihood of this risk? / Yes / No
Do you have any history of drug and/or alcohol misuse?
If Yes, does this pose a threat to you or anyone else?
What is the nature and likelihood of these risks? / Yes / No
Do you have a history of offending?
If there are any risks to yourself or others what is the nature and likelihood of these risks? / Yes / No
Are there any risks associated with entering, leaving, or working within your home (such as potentially dangerous animals, difficulty in physical access to the property)?
If Yes, please state risks / Yes / No
Is there any other information relating to risk that we need to be aware of?
Is there anyone else we should contact for information?
Your signature:
Date:

Thank you.

The ‘Moving On’ project staff will contact you within 2 weeks of receiving this referral.

Mental Health Matters Wales Charity No: 1123842 Company No: 6468412