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Would you like to refer someone else to our service?


We tackle social isolation in the North Berwick Coastal Ward. Our services include Scone Café and Coffee Connections meet-ups, befriending, Buddy Walks, monthly newsletter.

Once we receive your form, we’ll get in touch as soon as we can to talk this over.

For further information or help with completion of form, please call Project Manager Carol Stobie on 07940 203380 (Tuesday to Thursday 8.30am to 4pm).

    * DENOTES REQUIRED FIELDS

    1. DETAILS OF PERSON YOU ARE REFERRING

    Do you have their permission to share these details with us?*

    YesNo

    Name of of person being referred*

    Address of of person being referred*

    Contact Info

    Date of Birth

    Emergency Contact (if consent given for this)

    Relationship to person


    2. YOUR OWN DETAILS (IF REFERRING THE OTHER PERSON)

    Your name and contact details*

    How do you know this person?*


    3. HEALTH ISSUES AND CONTACTS

    Doctor (Name, Address and Telephone No.)

    Does the person you’re referring have any relevant physical or mental health issues we should know about? How does this affect their everyday life?


    4. WHAT BENEFITS DO YOU THINK THE PERSON WOULD GAIN FROM INVOLVEMENT WITH COMMUNITY CONNECTIONS?


    5. WHICH COMMUNITY CONNECTIONS SERVICE/S ARE THEY INTERESTED IN? PLEASE TICK ALL.

    Receive monthly Community Connections newsletter YES

    Scone Café (weekly drop-in gatherings) YES

    Coffee Connections meet-ups with other members YES

    Chumming to one or more local activities, making initial introductions YES

    Befriending (weekly calls or coffee meet-ups) YES

    Buddy Walks (one or more walks tailored to needs, with trained volunteer) YES

    If Befriending or Buddy Walks, what are their interests?


    6. IS THERE ANYTHING ELSE WE SHOULD KNOW THAT MIGHT HELP US MEET THEIR NEEDS?


    Date of referral*

    Signature of Referrer*


    * DENOTES REQUIRED FIELDS

    For further information or help with completion of form, please call Project Manager Carol Stobie on 07940 203380 (Tuesday to Thursday 8.30am to 4pm).

    All confidential details will be stored according to GDPR regulations and under our Safeguarding Policy (available on request) and shared only where consent is given.