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Castle Point Association of Voluntary Services

Befriending Application Form


Castle Point, Rayleigh & Rochford Referral Form

A referral into the CAVS Befriending Service may be through:  

a) Self-Referral: If you are making a self-referral please complete section 1 only.

b) Referral for Someone You Know: If you are making a referral for someone else, please complete section 1 with your personal details and Section 2, providing details on the person you are referring.

c) Referral via Organisations/Partners:  Please refer through the normal routes.

Section 1: Self-Referral

Full Name:

Home Address:

Postcode:

Your GP’s Practice Name: (self-referral only)

Your Email:

Tel (Home):

Mobile:

Date of Birth:

Please provide as much detail as you are able on why you would like to use this service:

Section 2: Referral for someone you know

Important: If you are referring in to the service on behalf of someone you know, prior consent must have been obtained from that person before completing this section of the form.

Please answer Yes or No if you have obtained verbal consent as appropriate
YesNo

Please indicate the nature of the relationship you have to the person you are referring. E.g. Family (Father, Mother, Daughter, Son) or a Friend, or a Neighbour:

Full Name:

Home Address:

Postcode:

Your GP’s Practice Name: (if known)

Your Email:

Tel (Home):

Mobile:

Date of Birth:

Please provide as much detail as you are able on why you are referring this person into the service:

Once you have completed the details, please press submit. Your information will reach our Ways to Wellness team who will be in direct contact you with you.

Our offices are open: Monday-Friday, 9am-5pm

If you have any queries, please telephone: 01268 214 000

Under GDPR all personal data obtained and held by us must be processed according to a set of core principles, which are outlined on our website www.cavsorg.uk within our Privacy Notice. The Privacy Notice explains how CAVS uses information about you, the way CAVS protects your data, how you may withdraw your consent at any time and your rights in relation to your personal information that is held by CAVS.  If you wish to have a copy of this, please let us know. CAVS strives to achieve compliance with the seven Caldicott Principles in relation to personal and confidential data. (Details are outlined, in our Privacy Notice).

For more information visit https://www.cavsorg.uk/governance/