Volunteer Visitor Referral Form
1. Details of person making referral
Complete this section if you are making this request on behalf of someone else.
Role / Job title
Relationship to the person being visited
Type of Referrer
Has consent been given by the person wishing to be visited?
2. Details of the person to be visited
Date of Birth
Is patient pre-amputation? Yes/No
Date of limb loss
Additional needs (e.g. language, learning, health, mental health needs)
We will aim wherever possible to meet the needs of services users as closely as possible however this will be dependent on whether we have a suitable match through our team of Volunteer Visitors.