VOLUNTEER STROKE SCHEME
The Volunteer Stroke Scheme
Dublin
Head Office - 01 4559036
REFERRAL APPLICATION FORM
(Please print & post this form to the above address)
REFERRERS DETAILS
Name
Date
Address
Phone
Occupation
DETAILS OF STROKE PERSON
Name
Date of Birth
Address
Phone
G.P.'s Name
Phone
Address
Date of Stroke
Is he/she referred to:
Community O.T.
Psychologist
Physiotherapist
S.P.&L.T
.
Present Condition - Mobility:
Speech & Related Problems:
Previous Occupation & Hobbies:
Relevant Stroke/Patient details: i.e. Warfarin medication etc.
Volunteer Stroke Scheme - Charity Number: 6989