Referral for 'Church Chat and support' - all areas of the UK
Hello! Do you need support or a friendly chat while isolating? Your local Church is ready to help!
This electronic form acts as referral for a person who is self-isolating due to COVID-19 (CoronaVirus), or those who are over 70 or in a health-risk group and therefore isolating, and in need of some extra friendly support.
Please complete for yourself or ensure you have permission from the person you are completing the form for. Only Priests or Ministers in charge of a church will receive your details and they will pass it on to a person with a DBS (safeguarding check) to support. The contact details will only be kept for 16 weeks from this form being submitted.
Anything that needs to be fetched will be left outside or posted through the letterbox. At no point will a support person enter your home.
* Required
Are you/ is the person you are referring self-isolating due to symptoms of COVID-19 (CoronaVirus)?
*
Yes - I have symptoms
No - I am not showing any symptoms, but am isolating due to previous health conditions or I am over 70
I am not sure
Name
*
Your answer
What support do you require?
Phone chat
Email chat
Food (Will be left outside the door in a bag and we will ring the doorbell and walk to a safe distance)
Medicine (we can help with this if you are isolating and showing no symptoms)
Baby items
A card or letter sent through the post
Prayers for you or your family
Information on Church services or events happening online
Other:
Would you prefer support from a female or male?
Female
Male
Don't mind
Clear selection
Email
Your answer
Address
Your answer
Phone number
*
Your answer
Comments
Your answer
By ticking this form you are confirming that you are consenting to Buxton Team Parish holding and processing your personal data for the purpose of support listed above (according to rules of GDPR). The details on this form will be destroyed in 16 weeks from the date of submission. You can find out more by phoning 01298 212 667 to speak to Reverend Liz. I consent to the Buxton Team Parish contacting me by the details above:
*
I consent to my data being kept for up to 16 weeks solely for the purpose of providing this support
Required
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