This referral has NOT been sent yet. You will be redirected to the listing's external referral form. Please complete the referral form there to submit the referral confirm Details Support & helpline for older people experiencing abuse by Hourglass (Safer Ageing) Who is this referral for? I am referring someone else Service access criteria Tick to confirm you have checked the service access criteria "The person experiencing abuse is over 60. Clients for casework must be over 60, live in Lambeth, Southwark, Lewisham, Greenwich and Bexley and have a safe contact method provided on referral form." Your Details Email Email is invalid We already have an account with this email. Please log in. Password Reset my password Log in First name Last name Your relationship to the person Organisation name Who are you referring? First name Last name Known as Date of birth Email Don't know / client doesn't have an email address Phone Address Line 1 Address Line 2 Town/City Postcode GP surgery NHS number Gender SelectFemale Male Transgender female Transgender male Non-binary Intersex Not specified Not known Other Additional referral details Do not enter protected health information (PHI) or any other personal data in these fields. What are the reasons for this referral? Sedentary lifestyle High body weight Finances Caring responsibilities Loneliness/isolation Employment Food Poverty Covid/Long Covid Mental health Substance misuse Transport Legal advice Managing a long-term health condition Day-to-day helping hand Victim of abuse Housing problem Bereavement Other: This field is required. Should the service provider be aware of any additional needs? Blind/partially blind Memory problem Hearing loss Housebound Does not speak English Poor mobility Learning and communication needs Physical disability Frail Other: Please share some brief details regarding this referral Is this a new referral? Yes No Does the person have an identified mental health issue or learning disability? Yes No Don't know Are there any risk factors? i.e. is the abuse still continuing Yes No Don't know What is the person's marital status? DETAILS OF THE ABUSE (please include where, when, and type of abuse) Is the person still in an abusive situation? Yes No Is the client still in contact with the perpetrator? Yes No Perpetrator Details if known. Including Name, relationship to the victim, age and gender Please tick allthat apply for the person iagnosed major depression or anxiety, short term memory loss or dementia Hearing Impairment Visual Impairment History of Falls Housebound, poor mobility, or unable to go out alone They have an identified have any other disability such as Alzheimer’s? They live on his/her own There is a history of self-harm They live with a dependent and that dependent considered ‘vulnerable’? They very little contact with family members (E.g. Once or twice a year.) They live with a family member but still feel isolated They lack confidence to access the community on his/her own They consent to having a volunteer They have physical or learning disabilities This field is required. If answered yes to any of the above questions, please supply further information Please list all professionals/services know to be involved with person i.e., Safeguarding, Police, Adult Social services, GP, Community Mental Health team Any other comments Confirmation and consent Tick to confirm you have gained consent to share this information with the service provider, your organisation and Joy Tick to confirm the service provider can directly contact the client Would you like to create an account? Make referrals faster next time you use Joy. Registered users can message service providers, submit reviews and track the progress of their referrals online. Password Weak password! Use at least 8 characters Use upper and lowercase characters (a-z) Use 1 or more numbers (0-9) Confirm password Please enter the same value again. required Submit Email: Password: Email
