Pantry Referral Form

Client Information




* YOU MUST COMPLETE THE CLIENT FIRST AND LAST NAME ABOVE.

Complete the following client information 












Agency Information








Establishing Needs


What support would you like from the Pantry Service?

Do you have a fully working fridge & freezer to store chilled and frozen goods?
How much do you currently spend on your weekly shopping bill?
Do you/household feel you eat enough fruit and vegetables throughout the week?
Little
Plenty
Do you feel  you currently have a balanced and nutritious diet?
Little
Plenty
Are there any dietary or health concerns the Pantry should be aware of?
In the last 12 months, did you or other adults in the household ever cut the size of your meals or skip meals because there wasn't enough money for food?
In the last 12 months, were you ever hungry, but didn't eat, because there wasn't enough money for food ?
In the last 12 months, did you or other adults in the household ever not eat for the whole day because there wasn't enough money for food?
In signing this document, I confirm that the above information is correct. I also give consent for my information to be reviewed and used for the efficient and effective running of the Pantry.