Referral Form

Referral Form

Anam Croí provide a range of support services for older people in the Claregalway and surrounding areas. Our referral form gathers essential information about an individual who may be in need of our services, enabling us to assess the suitability of our services to the individuals’ needs.

PDF Download

If you would like to apply for our services, please complete the online form and either email your supporting documentation to or send it to us by post at Anam Croí, Gort na Creige, Cregboy, Claregalway.

Our referral form is available for download so that you can complete it at a time and place that best suits you.

Please complete the form as fully as possible to avoid any unnecessary delays in processing your enquiry, by including the following:

  • Personal Details
  • Medical Details
  • GP/ Public Health Nurse Contact Details
  • Contact Details – Next of Kin (x2)

Multipage gravity

2Main two

Personal Details:

Special Dietary Requirements
Current Supports
Will Transport be Required?