Joining Re-engage call companion service in partnership with Parkinson’s UK

Re-engage call companion service in partnership with Parkinson’s UK is for people living with Parkinson’s or their carers. Please use this form to apply for or to refer someone to this service.

Are you applying for yourself or referring someone else?*

Applying for myself

Re-engage call companions in partnership with Parkinson’s UK is suitable for people who:

  • are over the age of 60
  • are living with Parkinson’s or caring for someone with Parkinson’s
  • can communicate on the telephone
  • speak and understand English
  • have a landline or good mobile phone signal

About you 

Your address*
Date of birth*

Monitoring

Re-engage collects the following information solely for monitoring purposes to ensure that we are fair, clear, and effective.

The following question is about your gender identity. What best describes your gender?*
This question is about your sexual orientation. Do you identify as:*

The Equality Act 2010 defines a person with disability as someone who has a physical or mental impairment that has a substantial and long-term adverse effect on their ability to perform normal day to day activities.

Do you consider yourself to have a disability?*

Emergency contact

In the unlikely event that you have an accident or become unwell, please provide us with the details of someone we can contact in an emergency.

Thank you for applying to be part of Re-engage

Thank you for applying to Re-engage call companion service in partnership with Parkinson’s UK

By submitting this form, you are confirming that:

  • The information that you have provided is accurate
  • You give us permission to hold your details within our secure Re-engage database and in accordance with our our privacy policy.

Making a referral

Thank you for referring an older person to Re-engage call companion service in partnership with Parkinson’s UK.

We want to be sure that Re-engage is right for them so please work with them to answer the following questions:

Re-engage call companion service in partnership with Parkinson’s UK are suitable for people who:

  • are over the age of 60
  • are living with Parkinson’s or caring for someone with Parkinson’s
  • can communicate on the telephone
  • speak and understand English
  • have a landline or good mobile phone signal
Is Re-engage call companion service in partnership with Parkinson’s UK suitable for the older person?*

Please check our website for other services that may be suitable.

About the older person

Their date of birth*
Their address*

Monitoring

Re-engage collects the following information solely for monitoring and evaluation purposes to ensure that we are fair, clear, and effective.

The following question is about gender identity. What best describes the older person’s gender? *

The Equality Act 2010 defines a person with disability as someone who has a physical or mental impairment that has a substantial and long-term adverse effect on their ability to perform normal day to day activities.

Does the older person have a disability? *

Emergency contact

In the unlikely event that the older person has an accident or becomes unwell, please provide us with the details of someone we can contact in an emergency.

Professional referrers

Are you part of Parkinson’s UK?
What sector do you work in?*
Organisation address*

By submitting this form, you are confirming that:

  • You have the permission of the older person to refer them to this service
  • The information that you have provided is accurate
  • You give us permission to hold your details within our secure Re-engage database and in accordance with our our privacy policy.

Friends and family referral

How do you know the older person?*

By submitting this form, you are confirming that:

  • You have the permission of the older person to refer them to this service
  • The information that you have provided is accurate
  • You give us permission to hold your details within our secure Re-engage database and in accordance with our privacy policy.
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