This form MUST only be filled in and submitted by referral agents.
Please note: Roundabout is no longer providing furniture via referrals to persons resident within the Worcester City boundary. This is a result of changes to the furniture provision policy of the South Worcestershire Discretionary Welfare Assistance Scheme.
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.