Online Referral Form

This form MUST be completed fully by the referral agent and NOT by the client. The referral agent must provide contact numbers for the client at the time of completing the referral request (it is not acceptable for the Referral agent to be the second contact number other than in exceptional circumstances). This must also include a mandatory alternative contact number. This is to minimise the risk of non-delivery due to the primary contact numbers not being answered. A referral request will not be processed unless an alternative contact number is provided which should not be the referral agent (unless there are exceptional circumstances).

Please read the Referral Terms before filling in the form. You will be required to agree to these terms before the information can be submitted.

Should you require an item not on the list then please contact the office before submitting the form and enter the details discussed in the ‘Other Information’ box below.

Please fill in the details in the boxes or select, as required.  An asterisk denotes a required field. When completed, please click the send button. If there are any omitted required fields, you will be prompted to fill them in before clicking the send button again. Once successful, a confirmation will display on screen and an email will be sent to the Roundabout office.

Please ensure all details are entered correctly.

    Referral Agency and Client Details

    Referral Agency

    Client

    Your ref.

    Title*

    Agency*

    Name*

    Address*



    Address*



    Town*

    Town*

    County*

    County*

    Postcode*

    Postcode
    (reqd. if known)

    Referral Agent

    Phone
    (reqd. if known) Alternative Contact Number* (mandatory)

    Name*

    Mobile
    (reqd. if known)

    Dept.

    Email

    Phone*

    Notes

    Mobile

    Email
    (reqd. if available)

     

    Payment details

    Who is to pay the charges?*   

    Purchase order Number:

     

    Applicant/Service users details

    Age of Client (select one)*:   16-2526-5051-6465+80+Prefer Not To Say

    No. of Children:  0-3 years   4-7 years   8-11 years  12-17 years

    Type of Premises* (select one)  HouseGround Floor FlatUpstairs FlatHMOOther

    Parking Available?* (select one)  YesNoPermit needed

    Is a lift available* (select one)  YesNo

    Priority of Applicant

    Please tick or mark yes to all criteria that apply

    Homeless or threatened with homelessness or in temporary housing

    YesNo

    Young/Single parent

    YesNo

    Family with children lacking essential items

    YesNo

    Vulnerable by:Disability/Health/Mental health/Age/SA or other - Please give details


    Low income/Financial crisis

    YesNo

    Ethnicity

    Employment status

     

    Furniture & Household Equipment Required

    Please complete the table below as appropriate. We aim to respond to the applicants/service users within 5 working days indicating if we have the items available. As white goods are often limited, please call to discuss availability and individual prices. Purchase Order numbers, where appropriate, must be supplied. We can be contacted on 01386 833030 between the hours of 09.00 and 13.00 Monday to Thursday or by e-mail: admin@roundaboutevesham.org.uk

    Access: Please provide as much details regarding access and the size of the property (e.g. upper floor/narrow stairs/ limited parking)

    Is delivery Required?* (if yes see below for charges)*

    YesNo

    Tenancy commencement date

    Furniture

    Price£

    Qty

    Furniture

    Price£

    Qty

    Double bed set (New)

    £POA

    Double bedding Starter pack

    £POA

    Single bed set (New)

    £POA

    Single bedding Starter pack

    £POA

    Single Bed Base (Used)

    £POA

    Rugs (Large)

    £POA

    Double Bed Base (Used)

    £POA

    Rugs (Small)

    £POA

    Double bed set   (base & mattress)

    £POA

    Cot

    £POA

    Single bed set   (base & mattress)

    £POA

    Table & 4 chairs

    £POA

    Bunk beds

    £POA

    Table & 2 chairs

    £POA

    Mattress double only

    £POA

    Dining chair

    £POA

    Mattress single only

    £POA

    Occasional table/TV Stand   (Pls. delete)

    £POA

    Sofa 3seater

    £POA

    Fireside chair

    £POA

    Sofa 2seater

    £POA

    Rise & Recline chair

    £POA

    Armchair(s)

    £POA

    Kitchen Starter pack

    £POA

    Chest of Drawers

    £POA

    Ironing Board

    £POA

    Wardrobe

    £POA

    Curtains, per pair

    £POA

    Bedside Cabinet

    £5

    Window height cm X Window Width cm

    cm:

    cm:

    Small desk

    £POA

    Window height cm X Window Width cm

    cm:

    cm:

    Toaster

    £POA

    Window height cm X Window Width cm

    cm:

    cm:

    Electric Cooker

    £POA

    Table Top Cooker

    £POA

    Hotplate

    £POA

    Microwave

    £POA

    Kettle

    £POA

    Washing Machine

    £POA

    Other Information:
    (i.e. Additional Items and Special requirements; e.g. Rug size(s); Fireside Chair Height to Seat & Depth)

    Delivery Charges:
    0 - 10 miles = £10
    >10 - 15 miles = £15
    >15 miles = £20 (Within our area)

     

    captcha
    In the box below, please enter the numbers and/or letters in the box above in the same order as you see them


    Tick to confirm you have read and accept our Referral Terms   

    Click this button to send the data as an email
    (this is only possible after acceptance of our terms)      

    Comments are closed.

    Opening Hours: Monday - Friday 9am - 1pm (except bank holidays) First and Third Saturday 9:00am – 1:00pm Tel: 01386 83 30 30