Request a Covid Recovery Volunteer - Referral Form

Please use this form to refer either yourself, or someone who could benefit, to the SCVS Our Neighbourhood Covid Recovery Volunteer service.
Please only refer someone else if you have their permission to do so.

Individual’s Name: (required)

Individuals Contact Number: (required)

Individuals Address: (required)

Individuals email address is applicable:

Please note that the Coronavirus Support Service is not a medical, crisis or urgent response service.

Please briefly describe why you / the person referred would like this service. (required)

Are there any risks we need to be aware of or any safeguards that we need to put in place? (required)

YesNo

If Yes, please provide further information

If this is not a self- referral; Has the individual being referred to the Covid Recovery Support Service given their permission for their details to be passed to us for the purposes outlined in our Privacy Policy?

Yes, I have permission to refer the individual / I am referring myselfNo, I do not have permission to refer the individual to the service

Please do not send the highly sensitive data if you have not had permission to refer the individual.

If you are referring someone else to the service, please add your details below.

Referrer Name:

Referrer Organisation / relationship to individual:

Referrer Contact Details:

Date of Referral: (required)

SCVS takes data protection very seriously. A copy of the SCVS, Privacy Statement can be found by visiting https://www.scvs.org.uk/privacy

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