registration form

VitalLinks Registration Form

Befriending schemes for older people are invited to join the VitalLinks network by completing this online form. It is free to join.

Network members can choose to have their scheme details published in the forthcoming online directory and will be able to securely update their own profile.

This project by Counsel and Care, the national charity for older people, their families and carers, aims to reduce loneliness and isolation.

The form takes approximately 10 minutes to complete and should be completed in one go. Please fill in as much detail as possible. The main contact name in section two is the only compulsory field. In addition, please provide either a contact telephone number or email or both. Where applicable, you can select more than one option by holding down the control key.

For more information contact the VitalLinks coordinator at Counsel and Care, Twyman House, 16 Bonny Street, London NW1 9PG Telephone 020 7241 8535 VitalLinks@counselandcare.org.uk

Section one

This basic information is designed to be made available to the public in an online directory

Name of the befriending scheme:

Name of the organisation (if different):

How and when can the scheme be contacted?:

Main telephone:
Email:
Website:

Office hours:

Monday	am:	pm:
Tuesday	am:	pm:
Wednesday	am:	pm:
Thursday	am:	pm:
Friday	am:	pm:

Location of the scheme

Geographical area covered by the scheme's activities:

Locality (village/town/city or enter 'nationwide'):

Overview of the scheme

What sort of befriending is offered? (choose one or more):

(select more than one option by holding down the control key)

Is the scheme specifically targeted to a particular group or groups? (tick if yes):

If yes, please indicate target group(s) (choose one or more):

If you choose other, please specify:

Is your service available for new clients?:
Are you looking for new volunteers?:
What sort of volunteers are involved?:
If you choose other, please specify:
For how long do you ask volunteers to commit?:

What other services are offered by the organisation? (choose one or more):
If you choose other, please specify:

Section two

The following details are designed to be made available only to other members of the network for information sharing between schemes

Contact details for individuals

Who is the main contact person e.g. scheme coordinator? (compulsory field):

Title:
First Name:
Last Name:
Role:
Direct Telephone:
Mobile:
Email:

Can anyone else be contacted about the scheme? (optional):

Second contact:

Title:
First Name:
Last Name:
Role:
Direct Telephone:
Mobile:
Email:

Third contact:

Title:
First Name:
Last Name:
Role:
Direct Telephone:
Mobile:
Email:

Scheme profile in depth

Please tell us more about the size and scope of your scheme

How many hours per week (approx. total) are worked by administrators (paid & unpaid)?:

Is the scheme coordinator position a staff or voluntary role?:
How many volunteers do you have at present?:
How many clients do you have at present?:

Is your scheme focussed on older people?:

Please describe the befriending relationships (choose one or more):

What is the duration and timing of relationships? (choose one or more):

If you choose other, please specify:

What type of organisation runs the scheme? (choose one or more):

If you choose other, please specify:

Skills and support exchange

Please suggest how you might share with other schemes

We would like support from other schemes in the following ways (choose one or more):

If you choose other, please specify:

We can offer support to other schemes in the following ways (choose one or more):

If you choose other, please specify:

Would you like to be in contact with other schemes located nearby? (tick if yes):

Snapshot of your scheme

Please share a brief description of your activities

What are your recent achievements?:

What are your current challenges and ongoing work?:

What are your future projects and plans?:

History and status of your scheme

When was the scheme established? (year):

Is your scheme a member of the Mentoring and Befriending Foundation?: (tick if yes)
Are you working towards Approved Provider Standard (APS)?: (tick if yes) Year started:
Have you achieved APS?: (tick if yes) Year of re/accrediation:

Section three

This information will be used for network development by the VitalLinks network coordinator

Please help the VitalLinks network to grow

Do you know of other befriending schemes at local/regional/national level that we might inform about the network?: (tick if yes)
Please supply their contact details (name, telephone and email if possible):

Which local, regional or national organisations do you use for support, information, training, etc?:

What would you like the VitalLinks network to offer you? (choose one or more):

If you choose other, please specify:

Do you have further suggestions/comments about the VitalLinks network?:

Your postal contact details

Street address:

City:
Postcode:

Online map locator

Region in which the scheme administration is based:

Unless nationwide please specify the geographical area within which your scheme operates for the clickable map

1 select a county or area from one of the six lists divided alphabetically
(n.b. G for Greater London and Manchester)
2 select one or more local authorities from the list of authorities that follows that county list (and which includes only the local authorities within those counties)

County/area A-D: