Referral form for White Goods via the Household Support Fund (Southampton)

FOR RESIDENTS OF SOUTHAMPTON POST CODES ONLY (SO14 – SO19)

This is what we are assessing for:

Single person: Tabletop Cooker or Fridge (1 of these items will be considered)
Family / Couple / Other Household: Cooker, Fridge, Fridge Freezer, undercounter Freezer or Washing Machine (only one item will be considered)
Household with disabilities or high-level health / care need: Cooker, washing machine, Fridge Freezer, undercounter Freezer or Fridge (one of these items will be considered).

Please give as much information as possible in this form as we cannot assess for funding without the completed information. All sections must be fully completed.

SCRATCH is working in conjunction with Southampton City Council on Household Support Fund and Local Welfare Provision. Please see link to SCC’s privacy policy Privacy policy (southampton.gov.uk)

Name of Referrer*

First NameLast Name

Referral Organization*

Referral Agency Phone Number*

Referral Agency E-mail address*

Client name(s)*

Client address*

Post Code*

Type of property (i.e. house, 3rd floor flat)

Client phone number*

Length of Time Engaged With This Client:*

Household Type*

Single PersonCouple / Other HouseholdFamily

Number of adults in household*

Date of birth of main applicant*

Number of children in household*

Dates of birth of all children*

Name(s) and dates of birth of any other adults in the property

White Good considered (subject to meeting criteria). Only 1 per household*

Fridge (available for any household)Fridge Freezer (families only, or where there is a medical need)Undercounter Freezer (families only, or where there is a medical need)Washing Machine (families only, or where there is a medical need)Electric Cooker (families, couples/other households or medical need)Table Top cooker (available for any household)Microwave (available for any household)

Primary Reason Of Need For the White Goods*

Period Of Time Without the white good*

Client's source of income (Employment/Benefits/Retired)*

Vulnerabilities in the household (Current and History of)*

Teams involved with this client / household’s care (Care package in place?)*

The main benefits that a discretionary funded white good would give to this client and / or their family? (We would like to know some feedback on what difference providing this help would make).*

Please give detail of the support you are providing for this client*

Where else have you tried to source this appliance for your client? *

Vulnerability (Tick All That Apply)*

Financial Hardship (e.g. Delayed Benefit Claims or Appeals)Age (Elderly or Frail)Family Circumstances (e.g. Dependent Children Under 5 or Pregnancy)Mental Illness/DisabilityPhysical Health/DisabilityOther Short-Term Crisis for which they are receiving support

Ethnicity*

Does anyone in the household have a disability?**

YesNo

*The definition of disability and disabled people aligns with the definition in the Equality Act 2010. Therefore, a disabled person is someone who has a physical or mental impairment that has a ‘substantial’ and ‘long-term’ negative effect on their ability to do normal daily activities.

Any further information

Referral form for White Goods via the Household Support Fund (Southampton)

Part A: White Goods Request - Referral Details