Temporary referral form

This form should be completed by an individual working at a recognised referring organisation (the "referring agent") on behalf of the intended recipient (the "applicant").

Referrals being made

Recipient / applicant details

Please give details of the intended recipient / applicant. This is the details of the client who is in need, not your details as the referrer.

Recipient's address (including postcode) - for Starter Packs, this should be the address they are moving into *

Starter pack referral

Previous address (including postcode) *

Reason for leaving previous address *

Other relevant information

Bedding

Please tick required items and select size.

Bedding
DuvetBedding setPillows

Bedding size
SingleDouble

Household items

Please tick required items.

Crockery, cutlery, pans and utensilsKettle

Acts435 referral

Recipient's date of birth (dd/mm/yyyy) *

Item(s) requested *

Amount requested - this should be the actual cost of the items above. The maximum amount is £150 for a high-value costed item (eg. large furniture, white goods) or £100 for other items. If you are applying for money towards a larger cost you must have the rest of the funds secured first. Please cost your item(s) and apply for the actual amount required (up to the maximum above), rather than simply applying for the maximum amount, to be fair to other applicants. Not following these guidelines will delay your application. *
£

Please give a paragraph explaining why the applicant requires the item(s) requested. This paragraph (which may be edited) will be the basis on which people are encouraged to donate towards meeting this need, so please include specific details of why the applicant has this particular need, and any relevant information as to why they are in their current situation. *

Referring agent

Collection

When would you ideally like to collect the pack/grant? Please note that we cannot guarantee to meet this but we will do our best. If you are flexible, please give a range of dates and/or times, or leave blank.

Declaration

I can confirm that the applicant named above is in genuine and urgent need, and is unable to obtain these items from another source at this time. *
Please tick to confirm

Diversity monitoring

This information is optional and for monitoring purposes only. It will not be considered when assessing the referral.