Make a referral for yourself or someone you know

Please read the ACE Neighbours Referral Criteria carefully before completing this form (click here).  This referral form can be completed by:

  • A referrer (such as a relative, friend or health & social care professional).
  • An individual wishing to refer themselves to the project.

Please be aware that St Monica Trust will file this information securely. It will only be shared with the relevant people working on the project.

Please complete all sections of the form. If you need any help with filling it in please call Catherine on 07817 632 963 or 0117 305 2365, Mondays to Wednesdays.

ACE Neighbours Referral / Application Form

  • PERSONAL DETAILS

  • REFERRAL CRITERIA

  • DETAILS OF THE REFERRER (IF NOT THE PERSON ABOVE)

  • CONSENT

  • REFERRAL REASON

  • INTERESTS

  • GP DETAILS

  • PERSONAL CIRCUMSTANCES

  • OTHER SUPPORT

  • HOW DID YOU HEAR ABOUT ACE NEIGHBOURS?