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AA Referral Form

This form is for self, professionals, and next of kin referrals to be made for the Active Ageing lunch clubs. In order to process the referral, Age UK Hertfordshire must collect personal data about you and/or the person you are contacting on behalf of. For information about how your details are used and stored by Age UK Hertfordshire, please read our privacy notice.

 

Please note, our lunch clubs are held in the districts of Broxbourne, Dacorum, East Hertfordshire, North Hertfordshire and Stevenage. If you are enquiring about clubs outside of these areas then please contact Herts Help on 0300 123 4044. If you live in Watford or Three Rivers, please look at our Clitheroe Health & Wellbeing Centre on our website to see whether we can support you.

Client Details

Please complete the following details about the person you wish to refer to Age UK Hertfordshire.

District
Does the client have memory loss/dementia?

We can only support people that have mild memory loss, if the client requires a dementia specific service, please contact Memory Support Hertfordshire 0300 131 3946

Does the client need support with personal care?

We are unable to provide any personal care at clubs, please contact Herts Help for alternative options.

Does the client need help with transport access to and from the Club?
Has your client has agreed to the referral being made to Age UK Hertfordshire
Should we contact you or the person you are referring to discuss the service?
Has your client given consent for Age UK Hertfordshire to store their information?