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4507865-68389500Kingdom Companions Self-Referral Form Personal Details Name:-58420-12446000D.O.B: -68580-7429500Address:-52705-10223500 Tel No: -5334034671000-501653683000Post Code:-546108699500E-mail:Social worker’s name(if applicable):-50165-76962000-68580-12509500 Tel No:-5334084963000Address:-68580-9398000-68580-11874500Post Code:-68580-10922000 Family Doctor(if known):-68580-9525000 Tel No:-3810033909000Family Details Next of Kin’s Name:-28575-8763000Relationship:-35560-8128000-20320-8953500-23495-11620500Address:-323853492500-330206286500 Post Code: -20955-12763500723900-11112500Tel No:Other Agencies you are involved with: -136486403100Outline of your current circumstances:-127006413500Reason for the referral: (Please include any isolation factors and how our service may contribute to reducing this)-157668555000Do you have any disabilities/health issues which we should be aware of? -6823980531 00 Does the client have any medical conditions which we should be aware of? How do you relate to other adults?-630628651300Please let us know about the current level of support you have from friends and family: -6096013398600Please detail below, the personal goal to be achieved: -685808572600-571546990000Can you tell us about your self-confidence and self-esteem? For example, has a recent life event negatively affected your confidence? -8188783819900-79375248920Risk ManagementDo you know of any situations which might trigger difficulties for you? For example, crowds, noise or public transport. -7620046991000Do you have any criminal convictions or are there any incidents involving the police that you think we should be aware of? Can you tell us about any risks in the home? -8188723956500General external environment e.g. driving access, street lighting etc. Please return completed referral form, marked Private and Confidential to:Nicci McDougall New Volunteer House 16 East Fergus PlaceKirkcaldyFifeKY1 1XTE-mail: Nicci@ ................
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