Pantry Referral Form
Client Information
First Name
Last Name
Is this a self referral?
Please select...
Yes
No
Referral Date (dd/mm/yyyy)
* YOU MUST COMPLETE THE CLIENT FIRST AND LAST NAME ABOVE.
Complete the following client information
Mobile Phone
Which Pantry do you want to use
Please select...
Southwark - Camberwell
South Kensington - Ixworth
Hackney - Stamford Hill
Islington
Kensal Resource Centre
Colwyn Bay
Midlands - Coventry
Norwich
Yorkshire - Leeds
Address
Postcode
Email Address
Date of Birth
(dd/mm/yyyy)
Gender
Please select...
Male
Female
Transgender
Non-binary
Intersex
Gender non-conforming
Other
Do not wish to disclose
Ethnicity
Please select...
Arab
Asian/Asian British: Bangladeshi
Asian/Asian British: Indian
Asian/Asian British: Other
Asian/Asian British: Pakistani
Black/Black British: African
Black/Black British: Caribbean
Black/Black British: Other
Chinese/Other ethnic group:Chinese
Chinese/Other ethnic group: Other
Gypsy/Irish Traveller
Mixed: Other
Mixed: White & Asian
Mixed: White & Black African
Mixed: White & Black Caribbean
Roma
White: British
White: Irish
White: Other
Client did not wish to disclose
Did not ask
Employment Status
Please select...
Working full-time
Working part-time
Jobseeker
Full-time Student
Carer
Cannot Work/Long Term Disability
Retired
Housing Situation
Please select...
Approved Probation Hostel
Bed and Breakfast
Children's Home/Foster Care
Currently resident at internal project
Direct Access Hostel
Foyer
HA general needs tenancy
Home Office Asylum Support
Hospital
Housing for older people
Living with family
Living with friends
Local Authority general needs tenancy
Mobile Home/Caravan
Owner occupation - low cost home owner
Owner occupation - Private
Prison
Private sector tenancy
Residential care home
Rough sleeping
Short life housing
Squat
Staying on buses
Supported housing
Tied housing or rented with job
Women's reguge
Any other temp accommodation
Other
Number of Adults in household
Number of Children in household
Agency Information
Name of Agency
Name of Referrer
Type of Agency
Please select...
Benefits
Charity/Third Sector
Council
Debt rehabilitation service
Drug / alcohol service
Education / training
Employment agency / job centre
Faith organisation
Housing service
Medical practice
Mental Health
Police
Prison
Probation
Social Care
Social Services
St Giles Project-Internal Referral
Youth offending team
Youth Support Service
Other health service
Other
Nature of Support Given
Phone
Mobile Phone
Email Address
Please give details, including any known risks/issues
Establishing Needs
Source of Referral
Please select...
Self
St Giles Project - Internal Project
Existing SGT client
Advice agency
Community mental health services
Community substance misuse services
Day centre
Education
Floating support
GP / Hospital / Health authority
Hostel
Housing Association
Job centre
Local authority - adult social services
Local authority - children's service
Local authority – community safety
Local authority – education
Local authority gangs unit
Local authority - housing / homelessness department
Local authority - other
Local authority - probation services
Missing People
Night shelter
Outreach / No Second Night Out (NSNO) team
Police
Police / safer streets team
Prison
Rolling shelter
Voluntary sector agency
Youth Offending Team
Other
Does the participant have any
Physical Disability
Learning Difficulty
Medical Condition
Offending History
Emotional Behavioral Difficulties
Care Leaver
Young Carer
Drug and Alcohol Issues
Mental Health Difficulties
Young Parent/Parent to be
Homeless
Other
Struggling to pay
Rent
Utility Bills
Groceries
Other (Please state below)
Other (please state)
Do you have a fully working fridge & freezer to store chilled and frozen goods?
Please select...
Yes
No
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
1
2
3
4
5
Plenty
Do you feel you currently have a balanced and nutritious diet?
Little
1
2
3
4
5
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?
Yes
No
In the last 12 months, were you ever hungry, but didn't eat, because there wasn't enough money for food ?
Yes
No
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?
Yes
No
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.
Signed
Date (dd/mm/yyyy
Contact Information