If you would like to make a referral for the 25th and/or 30th December 2019, please complete this form.

The information you submit will be kept in accordance with the Data Protection Act 1998. Please see https://www.ukeff.org/privacy-policy/

By signing this form you are confirming that the Client is aware of, and consents to, this referral and that we (UKeff) can share all information contained in this form with the Client.
The Client also consents for us to contact them directly to offer support and assistance and to maintain future contact with the referrer if the need arises.

UKeff is committed to equal opportunities and seeks to assist individuals from all sectors of the community. UKeff will not tolerate the less favourable treatment of anyone on the grounds of their gender, age, race, colour, nationality, ethnic or national origin, disability, marital status, sexual orientation, responsibility for dependents, trade union or political activities, religious or other beliefs, or any other reason which cannot be shown to be justified. This policy is subject to the requirements and legislative framework as outlined in the Equality Act 2010.
If roughsleeper or homeless, please provide hostel details or other contact point
If available
Please state the name, date of birth, gender and relation to the Primary Service User (eg child, spouse) who will be attending with the client
If referring for Christmas Day, please state the number of each of the meal choices (to assist with our meal planning)
State any dietary requirements/food allergies
Please select if a food parcel is required
Please detail any other required support for the Service User
Only if necessary (eg. GP, Social Worker, Probabtion Officer)
Please select all that apply. The information you submit will be kept in accordance with the Data Protection Act 1998.
Please add the relevant details for the client's problems
Office telephone number
Mobile number
Please select all that apply
Please add the relevant details for your referral
Parental/guardian responsibility: UKeff is unable to take responsibility for the care of an children who attend on any of the days – it is essential that the parent or guardian takes full responsibility for the care of and observation of any child/children accompanying them during their visit. Children must not be left unattended at any time, including toilet visits. Check box to confirm service user has acknowledged
Transport: UKeff is unable to provide transport for any of the service users during all the Christmas period. We encourage referring agencies to make their own transport arrangements – particularly on Christmas Day when there will be limited public transport, increased taxi tariffs and the likelihood of inclement weather.

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