Welfare support referral form

Please use this referral form to refer individuals into our Starter Pack or Acts435 services. Referrals must be made by one of our referral agencies.

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Important notes

Please note that Starter Packs and Acts435 crowd-funding are only available once each to any individual, and if a referral is accepted it must be collected by the referral agency and not the person being referred.

Starter Packs

Please note that Starter Packs are funded by charitable giving and therefore we are only able to offer them to single individuals moving from rough sleeping or temporary shelters/hostels to their own tenancies.

Referrals can take up to a week to be processed. You will be notified when your pack is ready to collect – please do not try to collect before then. Collections should ideally be made between 8am-4pm Tue-Thu.

Starter Packs must be collected within three weeks of being notified or you will have to make a new referral.

Acts435

Acts435 referrals should be for a specific, costed, item (or items), up to a maximum value of £120. If you put a referral in for items exceeding this value, it will delay your application.

We can only process one Acts435 referral per referrer at a time, and we do not take referrals for bonds or rent payments.

Acts435 is a crowdfunding service and is not guaranteed. Successful funding usually takes at least 3 weeks to obtain, and may be up to 5 (or not at all).

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").

Fields marked * are required.

Referrals being made

Please select at least one option: *

Applicant details

Please give details of the intended recipient.

Starter pack referral

Starter Pack items requested

Please note that Starter Packs are for individuals, not families. Pack contents may vary due to availability and may include good quality donated items.

Bedding

Please tick required items and select size.


DuvetBedding setPillows


Household items

Please tick required items.

CrockeryPansCutleryCooking utensilsKettle

Acts435 referral

Referring agent

Please give your details.



Collection

Declaration

This should be completed by you as the referring agent.


Diversity monitoring

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