Agency Referral Form
Referrer Information
Name of Agency
*
Contact Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Format: 00000 000000.
Back
Next
Referral Information
Details of the person you are referring
Date of Referral
*
/
Day
/
Month
Year
Date
Your reference no. for client if applicable
Client's Name
*
First Name
Last Name
Client's preferred contact method?
*
Telephone
Email
Text
Letter
Client E-mail Address
Client Phone Number
Format: 00000 000000.
When is the best time to call?
Morning
Afternoon
No preference
Client Date of Birth
*
-
Month
-
Day
Year
Date
Client NI Number (Preferred)
Client Address
*
Street Address
Street Address Line 2
Town
Post Code
Client's Housing Status
*
Private Tenant
Social Tenant
Home Owner
Living With Family
Homeless/Couch Surfing/No Fixed Abode
Unknown
Name of Registered Social Landlord
Is the individual currently receiving support from other services? e.g., Money Matters
*
Yes
No
If 'Yes' - please state which service and reason for support.
Is the individual a previous client of CHAP?
*
Yes
No
Unsure
Please confirm that the client given permission to share their details as contained within this form for the purposes of making a referral to CHAP?
*
Yes
Is there any known risk with this individual? e.g., do they require a two-person appointment/are they potentially violent/MAPPA etc.?
*
Yes
No
If yes, please specify risk involved. If this cannot be disclosed in writing, please call 030 0002 0002 to alert us of this risk.
Client's employment status:
*
Registered Unemployed
Unfit for Work
Inactive e.g., (due to disability/long-term illness)
Retired
Employed (full-time)
Employed (part-time)
Does the client live with a partner?
*
Yes
No
Partner's Name (this information allows us to check for conflict of interest):
First Name
Last Name
Partner's employment status (this information gives us an idea of the household circumstances):
Registered Unemployed
Unfit for Work
Inactive (e.g., due to disability/long-term illness)
Retired
Employed (full-time)
Employed (part-time)
Are there any children in the household?
*
Yes
No
If yes, how many children?
What does the client need help with? (select all that apply)
*
Welfare Rights (benefit check, application, appeal, etc.)
Housing (application, appeals, private let, eviction, rent/mortgage issues, etc.)
Money/Debt (budgeting, debt options, etc.)
Are you aware of any deadline dates in relation to the client's case? (such as application deadlines, court/tribunal/eviction dates etc...)
*
Yes
No
If yes, please advise of deadline date and circumstances:
Brief outline of client's situation and assistance required:
*
Submit
Should be Empty: