Member Recommendation Person being recommended Date of birth (We generally support people between the ages of 16 and 65 years old.) How do you prefer to be contacted* PhonePostEmail *Please note all fields marked with an asterisk are mandatory Next > Further details We may need to discuss any current support in place prior to progressing with recommendation. It would be helpful to understand how best to communicate with the person being recommended prior to meeting. We are unable to administer medication to members or any Epilepsy Rescue Medication. *Please note all fields marked with an asterisk are mandatory < Previous Next > Details of person making recommendation Do you have permission to make this referral?* YesNo Does the person know you are making this referral?* YesNo Is there a single shared assessment (SSA) that can be provided to support the assessment?* YesNo *Please note all fields marked with an asterisk are mandatory < Previous Next > Outcome Based Support At Neighbourhood Networks we work with members to increase their independence with the following outcomes. Please consider which of these outcomes you feel we can support the person being recommended with and provide a brief explanation of their current situation. As part of our recommendation process, we require a Note of Interest Form to be completed by the person being recommended. This can be completed and sent at the same time you make a recommendation or at the initial meeting with the potential member. Note of Interest Completed YesNo *Please note all fields marked with an asterisk are mandatory Thank you for completing this form. The information provided will be securely stored by Neighbourhood Networks in line with our Data Protection Policy. < Previous