Referral to the Godalming & Villages 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)
*
Awaiting payment of Universal Credit
Awaiting payment of JSA
Recently made redundant / reduction in work
Dealing with debt leading to food or fuel poverty
Other
How often do they need a shop?
*
Fortnightly
Monthly
One Off
How long do you estimate support will be needed (Maximum 3 months*)?
*If support is needed for longer than 3 months the Community Store will contact you as referrer to review arrangements
Most appropriate service(s)
*
In-store: Customer+carer
Collection only
In-store shop: Customer
In-store shop: Referring party
Other
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3. Customer details
Name
*
First Name
Last Name
Mobile or home 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
Age(s) of children
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
Other
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Any other info the Godalming & Villages Community Store team should be aware of?
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Submit referral
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