AGENCY REFERRAL FORM PLEASE COMPLETE THIS FORM AS FULLY AS YOU CAN. ONCE COMPLETED, POST IT TO: SCOTSCARE, FREEPOST LICENSE RSLK-KBRR-AGCK, 22 CITY ROAD, LONDON EC1Y 2AJ 1 – APPLICANT’S INFORMATION Title First Name Surname Date of Birth Age Gender Country of Birth Place of Birth Address City Post Code Home Phone Mobile Phone Email Address 2 – APPLICANT’S ACCOMMODATION Please tick the box which best describes your client’s accommodation status. Homeowner ☐ Council ☐ Local Authority ☐ Housing Association ☐ 1 1-1651081786586497649-.docx AGENCY REFERRAL FORM Private Rental ☐ Flat Share ☐ Lodger ☐ With Family ☐ Other (give details) ☐ Do they own any property? No ☐ Yes ☐ 3 – APPLICANT’S EDUCATION What is your client’s highest level of qualification? Level 1: SVQ/NVQ Level 1, GCSE Grades D -G, ☐ Foundation GNVQ, or City & Guilds Level 1 No formal qualifications Level 2: SVQ/NVQ Level 2, GCSE A*-C, Intermediate GNVQ, BTEC 1st Cert., or City & Guilds Level 2 Level 4: SVQ/NVQ Level 4, Level 4 Vocational Awards, BTEC HND/HNC, or City & Guilds Level 4 Level 3: SVQ/NVQ Level 3, A-Level, Scottish ☐ Higher, BTEC National Cert., or City & Guilds ☐ ☐ ☐ Level 3 Level 5: SVQ/NVQ Level 5, Level 5 Vocational Awards, or City & Guilds Level 5 ☐ Higher Degree (for example MA, PhD, PGCE) Degree (for example BA, BSc) 4 – APPLICANT’S EMPLOYMENT Has the applicant been employed within the last 5 years? No ☐ Yes ☐ If Yes, please give details of their last paid employment Employer Role Period Worked 2 ☐ 1-1651081786586497649-.docx ☐ AGENCY REFERRAL FORM 5 - WHO LIVES WITH THE APPLICANT Please give details of everyone who lives with you. First Name Surname Date of Birth Place of Birth Relationship to Applicant 6 – HEALTH ISSUES Does the applicant or anyone living with them suffer from a diagnosed illness or disability? If so, please give details. Name Illness or Disability 7 - REASON FOR APPLICATION 3 1-1651081786586497649-.docx AGENCY REFERRAL FORM Please explain the reason for the application. We do not pay debts, nor do we contribute towards the cost of items already purchased. Grants will not be paid directly to clients only to the referring support worker’s agency. Click or tap here to explain the reason for your referral. 8 - INCOME & EXPENDITURE Please indicate the amounts your client’s household receives and spends. Be prepared to provide proof of both income and expenditure quoted. Income Applicant Amounts below are: Weekly Partner ☐ Monthly Expenditure Attendance Allowance £ £ Rent/Service Charge £ Carer’s Allowance £ £ Council Tax £ Child Benefit £ £ Water Rates £ Child Maintenance £ £ Electricity £ Child Tax Credit £ £ Gas £ DLA or PIP – Care £ £ Mobile Phone £ DLA or PIP – Mobility £ £ Landline/Internet/TV £ Employment & Support Allowance £ £ TV Licence £ Family Member’s Contribution £ £ Travel £ Incapacity Benefit £ £ Launderette £ Income Support £ £ Insurance £ Jobseeker’s Allowance £ £ Food/Housekeeping £ Paid Employment £ £ Alcohol £ Pension Credit £ £ Tobacco £ Private Pension £ £ Childcare £ State Pension £ £ Hire Purchase £ Universal Credit £ £ Other – Click to specify £ 4 1-1651081786586497649-.docx ☐ AGENCY REFERRAL FORM Working Tax Credit £ £ Other – Click to specify £ Savings £ £ Other – Click to specify £ Student Financing £ £ Other – Click to specify £ Other Income £ £ Other – Click to specify £ Please specify DEBTS Please indicate the amounts owed and any repayments being made. Creditor Total Owed Applicant Repayments Partner Applicant Partner Click or tap here to enter text. £ £ £ £ Click or tap here to enter text. £ £ £ £ Click or tap here to enter text. £ £ £ £ Click or tap here to enter text. £ £ £ £ 5 1-1651081786586497649-.docx AGENCY REFERRAL FORM 9 – RELEVANT INFORMATION This section should be completed by the referring agency worker and should reflect the level of help being requested. i.e. the higher the financial amount being requested, the more information required. We expect that referring agencies will carry out a full assessment of their clients’ needs and supply all the necessary documents. Referrals not meeting these requirements will be returned to referrer. Your Client’s Social Networks Click or tap here to enter details of your client’s social networks. This can be family and/or friends. Your Client’s Housi