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Service Referral Form

This form is for you to refer yourself, a family member, a friend, or your client/patient to The Loneliness Prevention Project. In order to process the referral, AFC Fylde Community Foundation must collect personal data about you and/or your client/family member. For information about how your details are used, and stored, please to read our privacy notice.

If you are referring on behalf of someone else, please ensure that you have received their permission to do so, before submitting their data, and that you include your details in the relevant section.

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Who is being referred to the Loneliness Prevention Project?

Please tell us more about the person being referred.

First Name

Last Name

Email - optional

Address

Postcode

Contact Number

Date of birth

Are you...?

Self- referring

Referring on behalf of somene else

Reason for referral

If you are completing this form on behalf of yourself, we now have all the personal details that we need in order to start the referral process. Please scroll down to the bottom of the page, confirm that you have read the privacy notice and then click submit.

Referrer's Details

If you are completing this form on behalf of someone else (e.g. family member, client or patient), please complete the following section.

General Data Protection Laws (GDPR) dictate that consent must be obtained for a referral to be accepted and recorded. Please confirm that your client/patient/family member/ friend has agreed to:

This referral is being made to AFC Fylde CommunityFoundation *

First Name

Last Name

Email

Your Position/ Relationship to the Client

Contact Number

I have read the privacy notice, and agree to The Loneliness Prevention Project collecting my data via this form *

Thanks for submitting!

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