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 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
Your Name and surname (REFERRER)
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 (REFERRER) position in the agency
Your (REFERRER) phone number
Your (REFERRER) relationship with the person being referred
First name of the PERSON BEING REFERRED
Surname of the PERSON BEING REFERRED
What is the age of the PERSON BEING REFERRED?
18-25 years old
26-35 years old
36-49 years old
50 years old or over
Under 18 years-old
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This form was created inside of HOPE Coventry.