Service Information and Referral Form Service Information and Referral Form * indicates required fields Sightline’s befriending service works very simply. The stages are as follows: Referral – Send a completed form (below) to Sightline. Match – Sightline matches the person with a befriender and an initial call plan is agreed with all parties. Talk – Weekly befriending calls start on the agreed time and day. Review – After three to four weeks the initial call plan is reviewed. Safeguard – If there are serious concerns for someone’s immediate safety, Sightline call their GP or emergency contact. I confirm the following(please click/tick all the boxes)Consent* The person being referred has sight loss and/or visual impairment*Consent* The person being referred understands that Sightline calls are recorded*Consent* The person being referred knows they are being referred to Sightline*Consent* The person being referred understands that there is a waiting list*Sightline offers telephone befriending services to the sight loss community.Sightline does not offer counselling, mentoring or advocacy services, nor is Sightline’s telephone befriending service a suitable alternative for these services (please click/tick both boxes).Consent* I confirm that I have read and understood this statement*Consent* I understand that inappropriate referrals will be rejected*To learn more about SightlineYou can find out more about accessing or volunteering for our services by contacting us: Telephone No: 0800 587 2252 Email: info@sightline.org.uk Website: www.sightline.org.uk Personal InformationName* Preferred Title Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. First Name(s) Surname Date of Birth* Day Month Year Where did you hear about Sightline?*Primary Contact No.*Alternative Contact No.*If you do not have an email address, please tick this box I do not have an email address Email* Address* Address Line 1 Address Line 2 City County Postcode Occupation*Languages Spoken*Eye Conditions*Are you blind or have a diagnosed eye condition? If yes, please tick an appropriate box Blind from birth Blind later in life Diabetic Retinopathy Glaucoma Macular Degeneration Retinitis Pigmentosa Other – please specify Other eye condition*Befriending Service InformationReferrer's full contact details*Details of someone we may contact if we have concerns about your wellbeing*Consent given for form to be sent securely to Sightline via any method* Consent given for form to be sent securely to Sightline via any method*Statement of Consent(please click/tick ALL boxes)Consent* The person being referred consents to Sightline storing this information safely*Consent* The person being referred consents to Sightline contacting them, in order to set up the service and review this with me*Consent* The person being referred consents to Sightline contacting the nominated wellbeing contact, if we have wellbeing concerns*Statement of Referral(please click/tick ONE box only)Untitled* The person being referred is signing on their own behalf This form is being signed by someone else, with consent given verbally or in writing Statement of Emergency Contact(please click/tick box to confirm)I understand that as part of the use of the service, Sightline will contact Emergency Services if there are serious concerns about a befriended person’s immediate safety and/or welfare, or that of another person* I understand that as part of the use of the service, Sightline will contact Emergency Services if there are serious concerns about a befriended person’s immediate safety and/or welfare, or that of another person.*Consent* By submitting this form you consent to the data being used in order to process this referral.*Equal Opportunity Monitoring FormWe aim to be an equal opportunities organisation, and our policy is that everybody receives equal treatment regardless of sex, race, disability, sexual orientation, religion or belief, age, marital or civil partnership status, pregnancy/maternity or gender reassignment, where any of these cannot be shown to be a requirement for being a Service User and/or Volunteer. To assist us in monitoring the operation of our equal opportunity policy, and for no other reason, please answer the following questions.Gender: Which of the following best describes your gender? Male Female Prefer not to say Prefer to self-describe Gender (Self described)Gender Identity: Do you identify as trans? Yes No Prefer not to say Prefer to self-describe Gender Identity (Self described)Gender: Is the gender you identify with the same as your gender registered at birth? Yes No Prefer not to say Prefer to self-describe Gender: Is the gender you identify with the same as your gender registered at birth? (Self described)Age 16 – 24 25 – 29 30 – 34 35 – 39 40 – 44 45 – 49 50 – 54 55 – 59 60 – 64 65 – 69 70 – 74 75 – 79 80 – 84 85+ Prefer not to say Ethnicity: What is your ethnicity? Arab Asian or Asian British: Bangladeshi Asian or Asian British: Chinese Asian or Asian British: Indian Asian or Asian British: Other Asian or Asian British: Pakistani Black or Black British: African Black or Black British: Caribbean Black or Black British: Other Mixed: Other Mixed: White and Asian Mixed: White and Black African Mixed: White and Black Caribbean White: British White: Irish White: Other Prefer not to say Prefer to self-describe Ethnic origin is not about nationality, place of birth or citizenship. It is about the group to which you perceive you belong. Please tick the appropriate box:Ethnicity (Self described)Disability: Do you consider yourself to have a disability or health condition? Yes No Prefer not to say Prefer to self-describe Disability (Self described)Sexual Orientation: Which of the following best describes your sexual orientation? Heterosexual Gay Lesbian Bisexual Prefer not to say Prefer to self-describe Sexual Orientation (Self described)Religion and belief: Which of the following best describes your religion and belief? Buddhist Christian Hindu Jewish Muslim No religion or belief Sikh Prefer not to say Other. If other religion or belief, please write in: Religion and belief (Other)CaptchaCommentsThis field is for validation purposes and should be left unchanged. Skip back to main navigation
