Elderly Companions

Application form for person needing an Elderly Companion.

Please complete the form providing information about the person who needs the Companion.

*Please note: Our Companions cannot undertake any personal care or dispense medication.  Their duties can include light housework, cooking, odd jobs, driving and general companionship duties like accompanying on visits, excursions or activities and doing grocery shopping.

Contact information for the person Elderly Companions should liaise with during the placement process

Contact details

Personal details of the person needing the companion

Contact details


Marital Status of person wanting companion


Please give information about current state of health, mobility and any physical restrictions

Please answer the questions and provide more detail about the type of help that is required