FANE Referral Form for Friendship Mentoring Project

FANE Referral form for Friendship Mentoring Project
Name : / What support do you have in your life now?
Agency
Family / other Carer
Other – please describe :
What kind of things do the people who support you, help you to do?
Address :

Age : / What kind of things would you want FANE to help you with around friendship?
Phone Number s:

Your own number:
Emergency phone numbers
1.
2.
We need two numbers so that we can give them to your Friendship Builder so they have people they could contact if you had any difficulty or an emergency when you were out with them / What are you interested in or what are your hobbies?
What do you do to make and keep friendships now
Who are your friends
We need to know if there is anything you think a volunteer would need to know about you during the time they spend with you.

How will you travel to meet your Friendship Builder
I will travel independently Yes No
I will have to have support to get there Yes No
Do you use a mobile phone
Yes No
Do you need any help when you are out in public places such as:
Ordering a meal or a drink Yes No
Paying for things in shops Yes No
Finding your way around new places Yes No

Anything else
Is there anything else you think we should know to make sure it all goes well for you with the Project

When would you like to like to socialise . Circle all applicable :
Mon : Morn / Afternoon / Evening |
Tues : Morn / Afternoon / Evening |
Wed: Morn /Afternoon / Evening |
Thurs : Morn / Afternoon / Evening |
Fri : Morn / Afternoon / evening |
Sat : Morn / afternoon / evening |
Sun : Morn / Afternoon / Evening
Anything else you would like us to know?

Please send this form to
FANE
Ouseburn Farm
Ouseburn Road
Newcastle
NE2 1PA