Be-a-friend referral form

Please see our website www.cariadpettherapy.co.uk/be-a-friend for the criteria for a referral.

The information obtained from this form is confidential. 

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1. Name of the referred person *
2. Does the person smoke or anyone else in the house smoke? If yes, we will not be able to visit and take this referral further *
3. Has the person you are referring expressed a wish to use the Be-a-friend service?  *
4. Please explain how our service would be of benefit to the person being referred. *
5. Does the person being referred have regular contact from: *
Required
6. How old is the person being referred? *
7. Telephone number of the referred person *
8. Please provide the referred persons location within Pembrokeshire. *
9. Type of accomodation *
Required
10. Does the person have experience of, and a love for dogs? *
11. Does the person have a pet within their home? If so please describe.  *
12. In respect of mobility, how would you describe the referred person *
Required
13. How would you describe the referred persons general health? *
14. How would you describe the referred persons mental health? *
15. Name of the person making the referral *
16. Telephone number of the person making the referral *
17. Email address of the person making the referral *
18. Agency making the referral *
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