AGE CONCERN OLDHAM ADVOCACY SCHEME
Registered Charity Number 512496
REFERRAL FORM
The scheme is for older people who are confused or who have dementia, who do not have any
effective friends or relatives to support them and who would benefit from the services of an
advocate.
DETAILS OF PERSON REFERRED
Full Name:
Date of Birth:
Address:
Tel. No:
Referrers Name & Position:
Referrers Signature: Date:
Why does this person need an advocate?
Has this person given permission to have an advocate?
GP’s Name and Address:
Send to: Advocacy Co-ordinator
Age Concern Oldham
10 Church Lane
Oldham
OL1 3AN
NB: It would be preferable for the referrer to accompany the advocacy co-ordinator on
the initial visit.
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AGE CONCERN OLDHAM ADVOCACY SCHEME
Registered Charity Number 512496
OTHER SERVICES INVOLVED:
(e.g. Social worker, Community Psychiatric Nurse, home help etc.)
ANY ADDITIONAL INFORMATION
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