Health Buddy Referral Form

What is a Health Buddy? Do you know someone with a Learning Disability who needs support at a health appointment? The Health Buddy System is a peer advocacy support group of people with a learning disability who support people with a learning disability. If you know someone with a learning disability who would benefit from peer support for a health appointment please complete this form below and send to:
New Ideas, Canterbury Building, Exhall Grange Campus, Winding House Lane, Ash Green, CV7 9HP, Warwickshire Tel: 02476 361800 admin@newideasadvocacy.org.uk

Name: ... Address. Contact Telephone Number.. Needs support for a visit at:

Hospital

Doctors

Dentist

Nurse

Optician

Hearing

Podiatry

Please tick box

address of appointment: ... Needs support for:

Other please specify:

X1
150 140 130 120 110 100 90 80

X ??? *Long-term support

Check up

Tests

Advice

Treatment

Initial support

Please tick box

Date of Appt........Time. .. Department .. Referrers Name. Address Contact Telephone Number.

* Support with all appointments associated with particular intervention