Application/ Referral form for the 1:1 mentoring project and social groups
Friends Action North East offer Friendkit workshops, 1:1 mentoring and lots of social groups amongst other things. Once we receive your completed form we will arrange to meet with you to discuss what aspects of our project you would like to be involved in.

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All about you:
This section should be completed with the details of the person applying to join the project (not the person making the referral - there is a section further down for you to complete)
First Name
Last Name
Date of birth
MM
/
DD
/
YYYY
Email 
Address including postcode 
Phone number
Are you a person with a learning disability diagnosis? 
Are you a person with an autism diagnosis?
Please provide more details about your diagnosis if you would like to.
What kind of things do you need support with?
What are you interested in or what are your hobbies?
What support do you have in your life now? Is it through an agency or do you get support from family?
Which group or activity are you interested in?
How did you hear about us?
Have you ever been a victim of a Mate or Hate crime?
Do you have access to the internet at home?
Do you use...
Do you use social media?
Is there anything else you think we should know to make sure attending the groups or activities goes well for you?
Is there anything else you find difficult or need some support with that you think we should know about?
What is the best way to contact you?
Support / parents/ carers information:
We need to get contact details for 2 people who support you so we have their details in case of an emergency. This can be a parent/carer/relative or someone else who supports you.
Please provide details of your emergency contacts.
First emergency contact - full name
Email
Phone number
Relationship to applicant? 
Second emergency contact - full name
Email
Phone number
Relationship to applicant? 
Who has referred you to us?
If you are making a referral to us on behalf of the applicant please give us YOUR details here.
Full name of the person who is making the referral
Phone number
Email
Please let us know which organisation you are making the referral from
We also require 2 references (These should be professionals such as support agency, teacher, employer, therapist). We cannot accept a referral without these. One reference could be from the person who is making the referral.  
Please provide your two references here
First reference full name
Email
Phone number
Any other details, such as organisation/company/school etc
Second reference full name
Email
Phone number
Any other details, such as organisation/company/school etc
Would you like to go onto our mailing list to receive our newsletter and up to date information about our social groups and workshops? (Please make sure you have provided an email address)
Would your support like to be included on our mailing list? Please ask them to provide an email address if they wish to be added
Relevant email address
GDPR

We will automatically keep your details for 5 years. We keep your personal information safe and secure and we do not share your details with any other agencies without your permission.

You can contact FANE at any time to remove your details from our systems.led title
Please indicate that you have read and understood how we keep your information in line with data protection:
Image Consent
We sometimes take photographs and videos for our social media and for our funders. Would you be happy if we used your picture in our information?
Our Contact Details

info@friendsaction.co.uk

Friends Action North East

C/o Ouseburn Farm

Ouseburn Road

Newcastle upon Tyne

NE1 2PA

Tel: 0191 231 4327

Mob: 07932 959645

www.friendsaction.co.uk
FANE Equality and Diversity Monitoring Form
We are required to ask for this information for equality and monitoring purposes. This information will remain anonymous and confidential.
Please tell us your gender
Do you consider yourself to have a disability?
What is your ethnicity?
Asian or Asian British
Black, Black British, Caribbean or African
Mixed or multiple ethnic groups
White
Other ethnic group
What is your sexual orientation?
What is your Religion or Belief?
Date of birth (this is for our age monitoring)
MM
/
DD
/
YYYY
Submit
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