Visitor Service Referral Form Use this form to make a referral for the Visitor Service. DECLARATIONPlease check and mark the following: Declaration YES the person in question over or close to 65 YES the person is at risk of social isolation due to having no or very few visitors YES the person is able to contribute to a mutually beneficial friendship relationship YES the service has been explained to the person, and they have given their permission to be referred to Age Concern and for their details to be given to, and stored by, Age Concern CLIENT DETAILS First Name Middle Name Last Name Address Suburb City Wellington Porirua Lower Hutt Upper Hutt Other Post Code Email Home Phone Mobile Phone Date of Birth Gender Male Female Gender Diverse Living Alone Yes No Living in a Resthome Yes No Ethnicity Pakeha (NZ European) Maori Pasifika European (incl. British) Chinese Indian Other Asian Australian North American African Middle Eastern Latin American Other Unknown NHI Number (optional) GP name and location Next of Kin / Emergency Contact – Name Contact Phone Relationship CLIENT SITUATION Describe the client’s situation Other services the client receives Physical health issues Social health issues Mental health issues Hazards in the home (any hazards for AVS workers) * None Animals Client behaviour Family of client Hygiene Maintenance Neighbourhood Smoking Other Describe any hazards REFERRER'S DETAILS Referrer's Name Position Organisation Team Referrer's Phone Number Referrer's Email Address Submit Visitor Service Referral Form
