Referral Form

We ask the same questions of everyone referred to LASSN. Please do not be offended if some of them do not apply to you

Project you want to refer to

English at Home

Befriending

Connecting Opportunities

Consent

I confirm that the person being referred to LASSN consents to the following information being shared

Details of the Individual being Referred

First Name

Last Name

Street Address

Supplemental Address

City

Country

Postcode

Email address (if you have one)

UK Mobile Phone Number

Please specify the country code

Date of Birth

Level of Spoken English

No English

Basic

Good

Fluent

Preferred Spoken Language

Other Languages Spoken

Is an interpreter required for the first meeting?

If you ask for an interpreter, LASSN will instruct an interpreter to contact you so that we can arrange our first meeting.

Details of other people in household

Home Office Status

Date arrived in the UK

If you don’t know the exact date, please put 1st January for the year of arrival

Any other relevant background information

Reason for the Referral

How do you prefer to receive support?

Online (e.g. video calls)

Telephone

Face to face

At my house

Out of the house

Do you have a smart phone?

What mobile phone network do you use?

Do you have Zoom installed on your phone?

Would you like support installing/learning to use Zoom?

Managing Risks and Staying Safe

It is really important to us that you are safe when you are getting help from LASSN. It is also important you know what information is shared about you by your referral agency and LASSN.

We will keep all of your information confidential, and will only discuss this with people who need to know – which is usually the volunteer you are matched with, and any agencies you allow us to speak with. We ask all the people we work with the same questions. Please do not be offended if they do not apply to you.

Once matched, LASSN volunteers visit people in their own homes. Please tell us about any risk issues that might influence the way we offer help.

Note: Please include any issues of violence, involvement with criminal justice, mental or physical health problems, substance use, domestic abuse, exploitation etc

Consent

I confirm that the information I have provided on this application form is complete and true to the best of my knowledge

Referrer Details

How do you know the person being referred?

First Name

Last Name

Phone Number

Job Title

Group / Organisation

What happens next?

When this form is submitted, it is emailed to the Volunteers Managers at LASSN. You will also receive a copy via email. A Volunteer Manager will be in touch as soon as they can, to let you know what is happening with your referral.