REFERRALS

Client Name *

First

Last

Client Address *

If roughsleeper or homeless, please provide hostel details or other contact point

Client Postcode *

Client Mobile

If available

Client date of birth *

Client gender *

Male
Female
Other

Client's spoken language *

Please enter all languages your client knows

Interpreter needed for client? *

Yes
No

Are you able to interpret for your client? *

Yes
No

Referrer Name *

First

Last

Agency Name and Address *

Referrer Telephone *

Office telephone number

Referrer Mobile *

Mobile number

Referrer Email *

Email

Confirm Email

Referrer Job Title *

Other Contacts

Only if necessary (eg. GP, Social Worker, Probabtion Officer)

Reason for Referral *

Homeless/rough sleeper
Domestic abuse
Financial hardship
Other

Please select all that apply

Details of referral reason(s) *

Please add the relevant details for your referral reasons(s)

Does the client have any of the following problems/needs? *

Please select all that apply. For clothing, please see next section.

Details of client problems/needs *

Please add the relevant details for the client's problems you have selected above. For clothing, please see next section.

Clothing

Does your client need any clothing? *

Yes
No

For men:

Please select the items needed

For women:

Please select the items needed

Shoe size

Underwear size

Underwear (knickers) size

Underwear - bra size

Please enter the bra size if known (eg. 34C) or upper body clothing size (eg size 10-12)

Trousers size

Tops size

Coat size

Dress or Asian clothing size

Data Protection and Confidentiality *

The information you submit will be kept in accordance with the Data Protection Act 1998. By checking this box 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.

Clothing

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