PRACTITIONER REFERRAL FORM

Please complete the form for the person you are referring to Roar. Thank you.
Contact Information
Title / Forename(s) / Surname
Address
Post Code / Contact Tel No
Date of Birth / Do you live alone? / Yes  No 
Emergency Contact 1 – Relative/Friend/Neighbour/Doctor
Title / Forename / Surname
Relationship
Address / Post Code
Tel No / Home / Work / Mobile
Emergency Contact 2 – Relative/Friend/Neighbour/Doctor
Title / Forename / Surname
Relationship
Address / Post Code
Tel No / Home / Work / Mobile
Where did you hear about Roar?

ROAR HEALTH & WELLBEING CLUBS

Roar Clubs for Older Adults provides lunch with a tailored health and wellbeing programme. Transport to clubs is subject to availability of volunteers. Please  the most appropriate for you to attend.

West End Community Centre
5A Underwood Lane, Paisley / Mon / Houston
Houston & Killellan Kirk Hall, Houston / Wed
Johnstone/Elderslie
Elderslie Village Hall, Stoddard Square,
Elderslie / Tue & Thurs / Linwood
New Tweedie Hall, Bridge Street, Linwood / Wed
Gallowhill
Gallowhill Community Centre,
Netherhill Road, Paisley / Tue / Erskine
Bargarran Community Centre
Erskine / Wed
Sherwood Greenlaw Church
Glasgow Road, Paisley
(2 – 4 pm lunch is not provided at this club) / Tue / Lochwinnoch
McKillop Institute, Lochwinnoch / Thurs
Ralston
St Mark’s Church, Ralston, Paisley Current Waiting List Closed / Fri

ROAR PROJECTS

For more information on times, dates and venues for any of our projects please contact the Roar office on 0141 889 7481 Please  the one you are interesting in attending.

Breath of Fresh Air – Mainly aimed at men, this project is based around nature and environment with Clyde Muirshiel Rangers / Reels & Spiels – A chance to see films, programmes, local footage and an opportunity for a blether.
Well Invested - Exclusive Health & Wellbeing MOT by qualified physiotherapists who will assess your fitness and provide specialist exercises. / Craft Cafe – Offers older adults aged 60+ a safe, social and creative environment where they can learn new skills, renew social networks and reconnect with their communities.
Come Dine with Me – Sign up for 6 week cooking course, share tips and recipes and enjoy the meal you have made together. All FREE. / Information and Signposting – Stay connected to Roar and be informed of any new projects and events.

ONE TO ONE BEFRIENDING/TELEPHONE BEFRIENDING

Befriending is aimed at people who are socially isolated and may have mobility or other disability issues. This service offers the older adult the opportunity to meet a volunteer in their own homes or to be accompanied for a walk, shopping or other activity as agreed with Roar – Connections For Life. In addition to one to one befriending, we offer phone befriending for people who feel awkward about visits to their home but would still like someone to have a chat with. It can also be a lifeline in times of bereavement or ill health.

One to One Befriending / Telephone Befriending / Please the service you require

To be completed if you require One to One Befriending Service or Telephone Befriending

Please give details of any health concerns
Do you smoke? Please  / Yes  No  / Can you answer the door? / Yes  No 
Do you have problems with walking/mobility? / Yes No  / Can you answer the phone? / Yes  No 

Data Protection Statement

The information you provide on this form will be treated in the strictest confidence and will be used only for compliance of the Data Protection Act. We may check the information collected with third parties or with other information held by us. We may also use or pass to certain third parties information to prevent or detect crime, to protect funds, or in other ways as permitted by law.

By signing the application form you agree to the processing of personal sensitive data (as described above) in accordance with the Data Protection Act, 1998.

I agree to the data protection statement above and I certify that all statements given on this form by me are true and correct to the best of my knowledge.

Referrer’s Details

Name / Source of Referral (please ) / HSCP / Other
Work Address
Email Address / Telephone
Mobile / Date

Please return the completed form by e-mail to or send to

Roar – Connections for Life, West End Community Centre, 5A Underwood Lane, Paisley PA1 2SL

If you require any further information please contact ROAR Office on 0141 889 7481.

Roar – Connections for Life is a company limited by guarantee, (Company number: SC390855)

and a charity registered in Scotland (Charity Number: SC042041)