Companion Request Form
Please use this form for recording clients Information.   Please fill in as much information as possible.

This form is also to be used for self referral.


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Your Name *
Your Address *
Your Postcode *
Your Telephone Number *
Do you have call blocker or call guardian ? *
Your email address if you have one
Your Date of Birth
MM
/
DD
/
YYYY
We want to make the best possible match with a call companion. Please tell us about your interests and hobbies:
(i.e. hobbies, activities, travel, creative arts etc)
Any other information ?
if they have shared any other info that is helpful to us to find a befriending match:
Current Support
Finding out what support they are currently getting will help us better understand what support we can offer them.
What is your home situation ?
(i.e. living alone, carers, residential care setting)
Do you get support from family and friends ?
Clear selection
Are you getting any other support ?
 from service providers: e.g. mental health, another charity, carers support etc ...
Are you receiving carer support ?
If they are getting Carer support it would be really helpful to find out which agency are supporting them and what days and times they visit.
Days & Times
What time of day do you prefer to be called  ?
Any day you prefer to be called on ?
Any other infomation
Health & Wellbeing Information
Do they have any hearing impairment ?
Clear selection
Do you have any long term health conditions ?
Hearing, mobility etc ....
Do you have much contact with other people ?
ie .. Friends, neighbours family ...
Emergency Contact Information
Who can we contact in an emergency
Who can we contact in an emergency for you? *
Their Name
Their Telephone Number
Relationship to you
If Dr what surgery
Any other medical information you would like to share ?
Any other relevant information ?
I would like to be matched with a check and chat companion
I understand that by being involved in a Warminster Action Groups Check and Chat service, my details will be held in a confidential, secure database, which is only used for communications with staff. Once part of a check and chat companion group, the call companion coordinator and my call companion will hold my contact information for as long as I am part of call companions.I confirm that the above information is correct and that I agree to my details being held as set out here. Please tick the box below to confirm. I agree to the terms* *
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