PATIENT REFERRAL FORM

This is a live request for a volunteer - when submitting your first request you will receive a verification link to your email, once you have clicked this link you will automatically be registered and your referral will be live. All referrals after this will be live immediately.

If you are an approved referrer and would like to make a referral over the telephone, please call our Support Team on 0808 196 3382.

If you would like the individual to self-refer, please advise them to call a separate number - 0808 196 3646. Please note, this is only for individuals who meet specific criteria or who are considered medically vulnerable for another reason.

Please note a patient (hereafter referred to as client) could be an individual that needs support or a NHS service that requires volunteers providing they meet the referring criteria and would benefit from one of the 4 volunteer roles as determined by an approved referrer.

A referral form will need to be completed for each individual request eg if more than 1 volunteer is required or various types of support required.

Please ensure the client details reflect the name and location of where the support is required as this information will be sent to a volunteer.

- Please ensure you have read the instruction document.
- We cannot accept requests for patient transport that involve wheelchair users.
- You will receive a notification if we are unable to match a volunteer to support the client.
- Please note that we will process your personal data in accordance with our Privacy Notice - Referral Parties, which you can find here.

I am a referrer that represents: *

Client (Patient) or Organisation Name *

Date Of Birth *

Client (Patient) or Organisation Email Address

Client (Patient) or Organisation Contact Number *

Patient Safety Letter format preference *

Please enter the Client (Patient) or Organisation postcode and address *

Support Required *

You must select the correct support as this is matched to a volunteer with specific vetting for that role. An individual requiring shopping or prescription pick up is Community Support. A pharmacy/GP surgery/NHS site requiring the collection and delivery of many prescriptions/supplies is NHS Transport Support. IF YOU ARE UNSURE PLEASE CALL 0808 196 3382.

- Check in and Chat Support: Provides short-term telephone support to individuals who are at risk of loneliness as a consequence of self-isolation. - Check in and Chat Plus Support: Provides a regular check-in by telephone to the same individual for a duration of 10 weeks, with 3 calls taking place each week. - Community Support: Provides collection of shopping, medication or other essential supplies for someone who is self-isolating, and delivering these supplies to their home. - Patient Transport Support: Provides transport for patients who are medically fit for discharge or to support patients going to NHS appointments. - NHS Transport Support: Provides transport for equipment, supplies and/or medication between NHS services and sites. Also involves assisting pharmacies with medication delivery.

Do the patient(s) have suspected or confirmed COVID 19 (High Risk) *

Periodicity *
This will automatically alert a volunteer for the frequency requested - this is LIVE - it is not a registration form

Priority *

Referrer First Name *

Referrer Last Name *

Referrer Email *

(You will receive an approval link after your first referral, once you have confirmed this, you will receive your login details - Requests from NHS/Gov email addresses will then go live automatically, alternative addresses will need approval and may take up to 72 hours)

Referrer Contact Number *

Where did you hear about us? *

I confirm that the patient is aware of this referral and that I have permission from them to refer for support and for Royal Voluntary Service to use the information included in this form (including information about their health) for the purposes of providing support to them through the NHS Volunteer Responder Scheme.

YOU ARE ABOUT TO REQUEST A VOLUNTEER - THIS IS NOT A REGISTRATION FORM.