Language
English (UK)
Referral to the Community Store
For completion by support agency representatives on behalf of their clients. For assistance in completing the form, you can contact the team during opening hours on 07493435715 or ask for a call back by sending your number to communitystoregav@gmail.com.
1. Your details (referring party)
Referring organisation
*
Referral contact
*
First Name
Last Name
E-mail
*
example@example.com
Your contact number
*
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2. Referral details
Reason(s) for referral (select all that apply)
*
Furloughed / part-furloughed from work
Awaiting payment of Universal Credit
Awaiting payment of JSA
Absent from work due to COVID-19 (self-isolating) receiving SSP or no pay
Self-employed and not eligible for state support
Recently made redundant / reduction in work
Dealing with debt leading to food or fuel poverty
How often do they need a shop
*
One-off (for now)
Weekly
Fortnightly
Monthly
For how many weeks or months do you anticipate support will be needed?
You can contact us at any point to extend this period. If it runs to over six months the Community Store team will contact you as referrer to review arrangements.
Most appropriate service(s)
*
In-store shop: Customer
Collection only
In-store: Customer+carer
Home delivery (only where necessary)
In-store shop: Referring party
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3. Customer details
Name
*
First Name
Last Name
Home number
Mobile number
Please provide at least one contact number for customer
Postcode
*
Street Address
Street Address Line 2
City
State / Province
Post code for geographical analysis
Address for deliveries
Street Address
Street Address Line 2
Town
State / Province
Postal / Zip Code
No. adults in household (18+)
To help us gauge suitable volume and types of supplies
No. under 18's in household
To help us gauge suitable volume and types of supplies
Ages of children if known
Number of ppl needing shaving supplies
Number of ppl needing sanitary products
Known dietary requirements or allergies
And the numbers of adults / children affected by each
Known food preferences
Prefer instant / ready meal options
Include tinned veg
Cook from scratch
Oven available
Freezer space available
Microwave available
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Any other info to make the Community Store team aware of?
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Submit referral
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