72 Yorkshire Street Oldham
0161 660 6818
Twitter
Facebook-f
Instagram
HOME
HELP
ABOUT
CHAMPIONS
VOLUNTEERING
IMPACT
DONATE
CONTACT
REFERRALS
JOBS
HOME
HELP
ABOUT
CHAMPIONS
VOLUNTEERING
IMPACT
DONATE
CONTACT
REFERRALS
JOBS
HOME
HELP
ABOUT
CHAMPIONS
VOLUNTEERING
IMPACT
DONATE
CONTACT
REFERRALS
JOBS
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 (including English if applicable)
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
Reason(s) for referral
*
Please add the relevant information for your referral reasons(s) with as much detail of the circumstances as possible. For example: dates homelessness/abuse began, financial status etc.
Does the client have any of the following problems?
*
Physical health problems
Mental health problems
Prescribed medication
Alcohol abuse
Substance abuse
Court/police issues
Other
None
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 and any subsequent needs they have. For example: household items, carpets, food support, sanitary products. For clothing, please see next section.
Clothing
Does your client need any clothing?
*
Yes
No
For men:
Underwear (underpants)
Socks
Shoes
Trousers/jeans
Joggers
T-shirts
Jumper/hoodie
Coat/jacket
Please select the items needed
For women:
Underwear – knickers
Underwear – bra
Socks
Shoes
Trousers/jeans
Joggers
T-shirts/tops
Jumper/hoodie/cardigan
Coat/jacket
Headscarf hijab
Dress/abayah
Asian clothing eg shalwar kameez
Please select the items needed
Shoe size
UK2/EU35
UK3/EU36
UK4/EU37
UK5/EU38
UK6/EU39
UK7/EU40
UK8/EU41
UK9/EU42
UK10/EU43
UK11/EU44
UK12/EU45
Underwear size
XS
S
M
L
XL
XXL
XXXL
Underwear (knickers) size
6
8
10
12
14
16
18
20
Underwear – bra size
Please enter the bra size if known (eg. 34C) or upper body clothing size (eg size 10-12)
Trousers size
XS
S
M
L
XL
XXL
XXXL
Trousers size
XS
S
M
L
XL
6
8
10
12
14
16
18
20
Tops size
XS
S
M
L
XL
XXL
XXXL
Tops size
XS
S
M
L
XL
6
8
10
12
14
16
18
20
Coat size
XS
S
M
L
XL
XXL
XXXL
Coat size
XS
S
M
L
XL
6
8
10
12
14
16
18
20
Dress or Asian clothing size
XS
S
M
L
XL
6
8
10
12
14
16
18
20
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.
Phone
Send Referral
