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Letterbox referral form
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Name
(Required)
Dr
Miss
Mr
Mrs
Ms
Prof.
Rev.
Mx
Prefix
First
Last
Address
(Required)
Street Address
Address Line 2
City
Postcode
Country (UK)
(Required)
England
Northern Ireland
Scotland
Wales
Region
(Required)
East Midlands
East of England
London
North East
North West
South East
South West
West Midlands
Yorkshire and The Humber
Local Authority Area
(Required)
Amber Valley
Ashfield
Bassetlaw
Blaby
Bolsover
Boston
Broxtowe
Charnwood
Chesterfield
Derby
Derbyshire Dales
East Lindsey
Erewash
Gedling
Harborough
High Peak
Hinckley and Bosworth
Leicester
Lincoln
Mansfield
Melton
Newark and Sherwood
North East Derbyshire
North Kesteven
North Northamptonshire
North West Leicestershire
Nottingham
Oadby and Wigston
Rushcliffe
Rutland
South Derbyshire
South Holland
South Kesteven
West Lindsey
West Northamptonshire
in East Midlands, England
Local Authority Area
(Required)
Babergh
Basildon
Bedford
Braintree
Breckland
Brentwood
Broadland
Broxbourne
Cambridge
Castle Point
Central Bedfordshire
Chelmsford
Colchester
Dacorum
East Cambridgeshire
East Hertfordshire
East Suffolk
Epping Forest
Fenland
Great Yarmouth
Harlow
Hertsmere
Huntingdonshire
Ipswich
King's Lynn and West Norfolk
Luton
Maldon
Mid Suffolk
North Hertfordshire
North Norfolk
Norwich
Peterborough
Rochford
South Cambridgeshire
South Norfolk
Southend-on-Sea
St Albans
Stevenage
Tendring
Three Rivers
Thurrock
Uttlesford
Watford
Welwyn Hatfield
West Suffolk
in East of England, England
Local Authority Area
(Required)
Barking and Dagenham
Barnet
Bexley
Brent
Bromley
Camden
City of London
Croydon
Ealing
Enfield
Greenwich
Hackney
Hammersmith and Fulham
Haringey
Harrow
Havering
Hillingdon
Hounslow
Islington
Kensington and Chelsea
Kingston upon Thames
Lambeth
Lewisham
Merton
Newham
Redbridge
Richmond upon Thames
Southwark
Sutton
Tower Hamlets
Waltham Forest
Wandsworth
Westminster
in London, England
Local Authority Area
(Required)
County Durham
Darlington
Gateshead
Hartlepool
Middlesbrough
Newcastle upon Tyne
North Tyneside
Northumberland
Redcar and Cleveland
South Tyneside
Stockton-on-Tees
Sunderland
in North East, England
Local Authority Area
(Required)
Allerdale
Barrow-in-Furness
Blackburn with Darwen
Blackpool
Bolton
Burnley
Bury
Carlisle
Cheshire East
Cheshire West and Chester
Chorley
Copeland
Eden
Fylde
Halton
Hyndburn
Knowsley
Lancaster
Liverpool
Manchester
Oldham
Pendle
Preston
Ribble Valley
Rochdale
Rossendale
Salford
Sefton
South Lakeland
South Ribble
St. Helens
Stockport
Tameside
Trafford
Warrington
West Lancashire
Wigan
Wirral
Wyre
in North West, England
Local Authority Area
(Required)
Adur
Arun
Ashford
Basingstoke and Deane
Bracknell Forest
Brighton and Hove
Buckinghamshire
Canterbury
Cherwell
Chichester
Crawley
Dartford
Dover
East Hampshire
Eastbourne
Eastleigh
Elmbridge
Epsom and Ewell
Fareham
Folkestone and Hythe
Gosport
Gravesham
Guildford
Hart
Hastings
Havant
Horsham
Isle of Wight
Lewes
Maidstone
Medway
Mid Sussex
Milton Keynes
Mole Valley
New Forest
Oxford
Portsmouth
Reading
Reigate and Banstead
Rother
Runnymede
Rushmoor
Sevenoaks
Slough
South Oxfordshire
Southampton
Spelthorne
Surrey Heath
Swale
Tandridge
Test Valley
Thanet
Tonbridge and Malling
Tunbridge Wells
Vale of White Horse
Waverley
Wealden
West Berkshire
West Oxfordshire
Winchester
Windsor and Maidenhead
Woking
Wokingham
Worthing
in South East, England
Local Authority Area
(Required)
Bath and North East Somerset
Bournemouth, Christchurch and Poole
Bristol, City of
Cheltenham
Cornwall
Cotswold
Dorset
East Devon
Exeter
Forest of Dean
Gloucester
Isles of Scilly
Mendip
Mid Devon
North Devon
North Somerset
Plymouth
Sedgemoor
Somerset West and Taunton
South Gloucestershire
South Hams
South Somerset
Stroud
Swindon
Teignbridge
Tewkesbury
Torbay
Torridge
West Devon
Wiltshire
in South West, England
Local Authority Area
(Required)
Birmingham
Bromsgrove
Cannock Chase
Coventry
Dudley
East Staffordshire
Herefordshire, County of
Lichfield
Malvern Hills
Newcastle-under-Lyme
North Warwickshire
Nuneaton and Bedworth
Redditch
Rugby
Sandwell
Shropshire
Solihull
South Staffordshire
Stafford
Staffordshire Moorlands
Stoke-on-Trent
Stratford-on-Avon
Tamworth
Telford and Wrekin
Walsall
Warwick
Wolverhampton
Worcester
Wychavon
Wyre Forest
in West Midlands, England
Local Authority Area
(Required)
Barnsley
Bradford
Calderdale
Craven
Doncaster
East Riding of Yorkshire
Hambleton
Harrogate
Kingston upon Hull, City of
Kirklees
Leeds
North East Lincolnshire
North Lincolnshire
Richmondshire
Rotherham
Ryedale
Scarborough
Selby
Sheffield
Wakefield
York
in Yorkshire and The Humber, England
Local Authority Area
(Required)
Antrim and Newtownabbey
Ards and North Down
Armagh City, Banbridge and Craigavon
Belfast
Causeway Coast and Glens
Derry City and Strabane
Fermanagh and Omagh
Lisburn and Castlereagh
Mid and East Antrim
Mid Ulster
Newry, Mourne and Down
in Northern Ireland
Local Authority Area
(Required)
Aberdeen City
Aberdeenshire
Angus
Argyll and Bute
City of Edinburgh
Clackmannanshire
Dumfries and Galloway
Dundee City
East Ayrshire
East Dunbartonshire
East Lothian
East Renfrewshire
Falkirk
Fife
Glasgow City
Highland
Inverclyde
Midlothian
Moray
Na h-Eileanan Siar
North Ayrshire
North Lanarkshire
Orkney Islands
Perth and Kinross
Renfrewshire
Scottish Borders
Shetland Islands
South Ayrshire
South Lanarkshire
Stirling
West Dunbartonshire
West Lothian
in Scotland
Local Authority Area
(Required)
Blaenau Gwent
Bridgend
Caerphilly
Cardiff
Carmarthenshire
Ceredigion
Conwy
Denbighshire
Flintshire
Gwynedd
Isle of Anglesey
Merthyr Tydfil
Monmouthshire
Neath Port Talbot
Newport
Pembrokeshire
Powys
Rhondda Cynon Taf
Swansea
Torfaen
Vale of Glamorgan
Wrexham
in Wales
Date of Birth
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
Year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
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1963
1962
1961
1960
1959
1958
1957
1956
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1954
1953
1952
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1950
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1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Phone
(Required)
Mobile
Email
Referrer (if not self-referring)
Name
Phone
Email
Relationship
If professional referring, employer
How did you hear about Omega?
Your Emergency Contact
Name
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Phone
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Email
Relationship
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A bit about you
Would you prefer a pen pal who is
Male
Female
Don't mind
Would you consider being matched to a younger pen pal befriender
Yes
No
Please tick which of these apply to you:
Additional information
(Required)
Lives alone
Over 75
Bereaved
Caregiver
Former caregiver
Socially isolated
Your general hobbies and interests (tick all that apply)
(Required)
Animals
Arts/Crafts
Cooking/Food
Culture/History
Family
Gardening
Music
Outdoors
Reading
Sports/Fitness
Please write down some specific details about your hobbies and interests; we need this information to match you up with an appropriate pen pal
Significant life event(s) / information
Please tick which ethnicity you identify with
Asian
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Black
Black British
Mixed
Other
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Would you describe your sexual orientation as
Heterosexual
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Other
Prefer not to say
How did you hear about Omega?
Storing of my information on Omega's databases
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I agree to receiving Omega communications and to the storing of my information on Omega's databases
Omega Newsletter
I would like to receive Omega’s e-newsletter to hear news about Omega’s vital work to keep older people connected and living well
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01743 245 088
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