Welfare support 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").

Fields marked * are required.

Referrals being made

Please select at least one option: *

Starter PackActs435 Grant

Applicant details

Please give details of the intended recipient.

Please leave this field empty.

Applicant's full name *

Applicant's age *

Applicant's best contact phone number

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

Referring agent

Please give your details.

Your name *

Your organisation *

Your email address *

Your telephone number *

Is the applicant a new or existing client of yours *
New clientExisting client

Do you intend to continue supporting the client? *
YesNo

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

This should be completed by you as the referring agent.

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.

Applicant's gender
---MaleFemaleOther

Applicant's ethnicity
---White: English/Welsh/Scottish/Northern Irish/BritishWhite: IrishWhite: Gypsy or Irish travellerWhite: OtherMixed/Multiple: White and Black CaribbeanMixed/Multiple: White and Black AfricanMixed/Multiple: White and AsianMixed/Multiple: OtherAsian/Asian British: IndianAsian/Asian British: PakistaniAsian/Asian British: BangladeshiAsian/Asian British: ChineseAsian/Asian British: OtherBlack/African/Caribbean/Black British: AfricanBlack/African/Caribbean/Black British: CaribbeanBlack/African/Caribbean/Black British: OtherOther: ArabOther

Applicant's disabilities (if any)