Referral Form (Professional Use Only)This form is for the referral of clients to UKeff by professionals.Client Name *FirstLastClient Address *If roughsleeper or homeless, please provide hostel details or other contact pointClient Postcode *Client MobileIf availableClient date of birth *Client gender *MaleFemaleOtherClient's spoken language *Please enter ALL languages your client knows (including English if applicable)Interpreter needed for client? *YesNoAre you able to interpret for your client? *YesNoReferrer Name *FirstLastAgency Name and Address *Referrer Telephone *Office telephone numberReferrer Mobile *Mobile numberReferrer Email *EmailConfirm EmailReferrer Job Title *Other Contacts Only if necessary (eg. GP, Social Worker, Probabtion Officer)Reason for Referral *Homeless/rough sleeperDomestic abuseFinancial hardshipOther Please select all that apply Reason(s) for referral *Please add the relevant information for your referral reasons(s) with as much detail of the circumstances as possible. For example: dates homelessness/abuse began, financial status etc.Does the client have any of the following problems? *Physical health problemsMental health problemsPrescribed medicationAlcohol abuseSubstance abuseCourt/police issues OtherNone Please select all that apply. For clothing, please see next section.Details of client problems/needs *Please add the relevant details for the client's problems you have selected above and any subsequent needs they have. For example: household items, carpets, food support, sanitary products. For clothing, please see next section.ClothingDoes your client need any clothing? *YesNoFor men:Underwear (underpants)SocksShoesTrousers/jeansJoggersT-shirtsJumper/hoodieCoat/jacketPlease select the items neededFor women: Underwear - knickersUnderwear - braSocksShoesTrousers/jeansJoggersT-shirts/topsJumper/hoodie/cardiganCoat/jacketHeadscarf hijabDress/abayahAsian clothing eg shalwar kameezPlease select the items neededShoe sizeUK2/EU35UK3/EU36UK4/EU37UK5/EU38UK6/EU39UK7/EU40UK8/EU41UK9/EU42UK10/EU43UK11/EU44UK12/EU45Underwear sizeXSSMLXLXXLXXXLUnderwear (knickers) size68101214161820Underwear - bra sizePlease enter the bra size if known (eg. 34C) or upper body clothing size (eg size 10-12) Trousers sizeXSSMLXLXXLXXXLTrousers size XSSMLXL68101214161820Tops sizeXSSMLXLXXLXXXLTops sizeXSSMLXL68101214161820Coat sizeXSSMLXLXXLXXXLCoat sizeXSSMLXL68101214161820Dress or Asian clothing sizeXSSMLXL68101214161820Data Protection and Confidentiality *The information you submit will be kept in accordance with the Data Protection Act 1998. By checking this box you are confirming that the Client is aware of, and consents to, this referral and that we (UKeff) can share all information contained in this form with the Client. The Client also consents for us to contact them directly to offer support and assistance and to maintain future contact with the referrer if the need arises. UKeff is committed to equal opportunities and seeks to assist individuals from all sectors of the community. UKeff will not tolerate the less favourable treatment of anyone on the grounds of their gender, age, race, colour, nationality, ethnic or national origin, disability, marital status, sexual orientation, responsibility for dependents, trade union or political activities, religious or other beliefs, or any other reason which cannot be shown to be justified. This policy is subject to the requirements and legislative framework as outlined in the Equality Act 2010. MessageSend Referral
