ALONE Service’s Referral Form

If you are making a referral to ALONE on behalf of someone else, please make sure you have the person’s consent to do so. If possible, complete this referral form in the company of the person being referred.

Make a referral for a relative

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Referral from a Relative

I would like to refer a Relative
Please fill out your own details here: 
Consent:
In order to process the referral, you must confirm that consent has been received from the older person and the date that it was received:
Please read ALONE's privacy statement
Key Information about the Older Person:
Please use the key information section below to fill in the information about the person you are referring.
Please note that the person should be over 60+. Date format DD/MM/YYYY
The area where the person lives such as Kilmainham, Dundalk, Kilkenny City, Buncrana.
To find the EIRCODE, please visit EIRCODE FINDER
Please include name, contact details and relationship.
How can ALONE support? Please select one or more of our services below:
A visit from a trained and Garda Vetted volunteer in the home for a minimum of 1 hour per week.
A friendly telephone call with a trained and Garda Vetted volunteer on chosen days of the week.
Support from our staff around housing difficulties, finance, safety and security or physical or mental well being.
Support from our staff providing information around assistive technology to support Older People.  .
What is are the main reasons ALONE's support is needed? Is it loneliness, physical health, dementia, mental health, housing difficulties, or other?
Are you aware of any risks or potential risks to our staff visiting this person's home?
Are you aware of any risks or potential risks to our staff visiting this person's home?
Please note:
When you press the submit button below you will see a summary of your form.

You must press the confirm button on the summary page for the referral to be completed. 

You will receive a confirmation email once the referral has been received by ALONE. 

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