Good Neighbours Coventry under 50s referral form
Good Neighbours Coventry helps vulnerable people during COVID-19 by connecting them to volunteers that can shop on their behalf, as well as befriending them over the phone to tackle isolation.

As a referrer, please fill in this form accurately. Please start by entering YOUR email address.

If you have any queries, contact the Good Neighbours Under 50s Coordinator, Bernardo: or 07450 693897.

Over 50s can be referred by email to .

Good Neighbours Coventry was set up by the charity HOPE Coventry in 2016, co-founded by Together for Change and Age UK Coventry and Warwickshire.

The full data privacy policy for HOPE Coventry can be viewed at The information you input here will:
-be stored securely
-not be passed on to or shared with other parties without the client's explicit consent
-be destroyed whenever you or the client request it
Email address *
Your Name and surname (REFERRER) *
Your answer
Name of your referral agency *
This is the service or agency that you work for/are associated with, that is making the referral: council department, a GP surgery, hospital, food hub, church, community centre, etc.
Your answer
Your (REFERRER) position in the agency *
Your answer
Your (REFERRER) phone number *
Your answer
Your (REFERRER) relationship with the person being referred *
Your answer
First name of the PERSON BEING REFERRED *
Your answer
Your answer
What is the age of the PERSON BEING REFERRED? *
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