ALONE Service’s Referral Form

Make a referral for yourself

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ALONE Self Referral Form

Key Information:
please note that ALONE is a charity that supports people aged 60+
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?

Professional Supporter Details
Please use this section to provide us with the details of a medical or social professional. We may need to contact this person in advance of our first visit. Please confirm below if we have the permission to do so.
Consent:
In order to process the referral, you must confirm that consent has been received and the date that it was received:
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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