Would you like to arrange for someone to be visited by one of our volunteers

If you or someone you know are interested in being visited by one of our volunteers, please complete the form below.

* indicates a required field

Please note; As our resources are limited, it is important that we use them as best we can, offering those that can get out and about, or already have some level of visits to their home, the chance to visit one of our Happy Hubs instead.

If you would like to refer someone to our Happy Hubs, please select the Happy Hubs Tab.

Details of person to be visited

First Name*

Last Name*

Date of Birth*

dd/mm/yyyy

Gender

Please indicate their ethnic origin

Telephone*

Does the person to be visited have an email address?

Location

We use this to help allocate our volunteers

Address*

Town / City*

County*

Post code*

Additional Contact

Name

Telephone

Relationship

Should this be the first point of contact?

Hobbies and Interests

Please tell us what you can about the person to be visited, for example, their hobbies and interests.

Does the person to be visited smoke?

Does the person to be visited have any pets?

Preferences

In order to help us "match" the person to be visited with one of our volunteers we would be grateful if you could answer the following questions:

Do they have a preference whether their visitor is a male or female?

Do they have a preference as to what time they would prefer a visitor to call?

Additional Information

Is the person housebound?

Does the person use a wheelchair?

Is the person able / willing to socialise ?

Does the person have any memory problems?

Does the person to be visited already receive visits on a regular basis?
For example by carers, relatives

Are there any known risks associated with this person?

Please describe any mental health issues that this person may have e.g. depression, Alzheimer’s (please indicate if there are any significant behavioural issues), psychosis etc.

Referring Information

Please indicate who is referring the person to be visited to the Happy at Home Project?

Contact Name*

Contact Telephone*

Contact Email

Where did you hear about
the Happy at Home Project?

Please confirm you are happy to receive emails from the Happy at Home Project.