Client Referral Form

Fields marked with an * are required

1. Referrer Details

1.1. Your name *

1.2. Your company or agency

1.3. Your email address *

1.4. Your telephone

1.5. Fax number (if applicable)

1.6. Your company address and postcode

1.7. Your relationship to the client

1.8. How long have you known the client? *

2. Client Details

2.1. Client Name *

2.3. Client's Date of Birth (dd/mm/yyyy) *

2.4. Client's Age *

2.5. Client's national insurance number (if they have one)?

2.7. Please submit the client's current address if available: Help Text

2.8. Client's telephone number *

2.9. Does the client have any dependents?

- If you have selected YES above, please provide details below

3. Important Contacts Information

3.1 Next of Kin / Emergency Name: Help Text

3.3. Next of kin contact address

3.3. Next of kin contact number:

3.4. Does the client have a GP?

- If yes, please supply a name and address (or contact number):

3.5. Does the client have a social worker?

- If yes, please supply a name and address (or contact number):

- If yes to above, what is the reason for a social worker?

3.6. Is the client in receipt of any benefits? Please tick all that apply:

If you have recently been granted refugee status and have not applied for benefits please do not tick any boxes.

Income Support
Jobseekers Allowance (JSA)
Child Benefit
Child Tax Credit
Housing Benefit
Council Tax Benefit
DLA
Pension

3.7. If you have ticked any of the above, please provide details of how much you receive for each benefit:

Terms and Conditions

The client named in 2.1. must have given the referrer authority to submit this referral form and agrees that the referrer be advised of any outcomes should no details have been provided in 2.8.

The client must be able to provide at least 1 verifiable form of identification before any assistance with housing or reintegration support can be made.

Please note that Stride Partnership CIC will only provide support to individuals that have been recently awarded either (a) person with humanitarian protection or (b) Refugee Status with leave to remain. We do not cater to any other client groups.

Disclaimer and Declaration:

Housing history, risk assessments and additional support requirements will be assessed by us at the next stage. We may be required to share this information with external support agencies; these agencies may include, DWP, Social Services, Mental Health Services. This list is not exhaustive and we may also be required to consult with other agencies, in order to provide the client with the necessary appropriate services. The exchange of this information will be on-going to enable Stride Partnership to continue to provide the service to meet the needs of the client. At times we may also use the information for service planning, monitoring service and research.

Client Referral Form