Healthwatch Doncaster - Reaching Out

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Before completing this form: Please be aware that the Reaching Out service is provided by volunteers for the purpose of a general conversation, volunteers cannot provide specialised support such as counselling. Thank you

Please tell us your name, email address and phone number *

Please tell us the name of the person you are referring to the Reaching Out telephone support service. *

Please tell us the phone number and e-mail address of the person who you are referring for Reaching Out telephone support *

Is the person being referred

Self-isoloating

In the 'Shielding' group of patients

Not self-isolating or shielding

Clear selection

I/the person being referred has given my/their permission for my/their information to be shared and I/they agree that Healthwatch Doncaster can hold on to my/their information and use it as part of the Reaching Out project *

YES

I am *

the individual requesting help and support

the individual's representative and they have given me permission to share their information with Healthwatch Doncaster

Thank you for your help and support. We value you and the work that you are doing to help support isolated people in Doncaster. The Healthwatch Doncaster Engagement Team will be in touch and keep you informed about next steps.

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