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
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
Mobile Phone/Phone number
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
Primary Language
Please select...
English
Acholi
Albanian
Amharic
Angolan
Arabic
Bengali
British Sign Language (BSL)
Czech
Eritrean
Estonia
Ethiopian
Farsi
French
German
Greek
Hungarian
Italian
Krio
Kurdish
Latvian
Lingala
Lithuanian
Ndebele
Polish
Portuguese
Punjabi
Romanian
Russian
Serbo-Croat
Slovakian
Slovenian
Somali
Spanish
Sudanese
Swahili
Swedish
Tigrinya
Turkish
Urdu
Yoruba
Did not ask
Client did not wish to disclose
Employment Status
Please select...
Full time work
Part time work
Unable to work
Currently looking for work
Student
Retired
Carer
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
Do you identify as neurodivergent (e.g., ADHD, autism, dyslexia, or other cognitive differences)? This helps us provide the best support for you
Please select...
Yes
No
Prefer not to say
Not sure
(Optional) If you'd like to, please share any specific needs or support that would make your experience with us better:
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
What support would you like from the Pantry Service?
Employment, Training, Education
Housing
Finance & Debt
Health and Wellbeing
Other (Please state below)
Other (please state)
Are there any dietary or health concerns the Pantry should be aware of?
Would you also like to know about any of these? (tick as many as you like)
Housing Support/ Advice
Cooking workshops (e.g., how to cut on a budget, healthy eating, etc.)
Digital inclusion (e.g., how to use your device, or help to buy one)
Financial income support (e.g., benefit entitlement, or budgeting)
Support with utility costs (e.g., gas, electric, water, energy saving)
Debt advice
Health & Wellbeing support / activities
Community activities to reduce social isolation
Volunteering opportunities or employment support
Other (please state)
Do you feel you/your family has a balanced and nutritious diet?
Yes
No
How many days a week do you/your family eat fruit and vegetables (including fresh, tinned, frozen, dried)? (Tick One)
Never
1-3 days
4-6 days
Every day
How well would you say you are managing financially? (Tick One)
Living comfortably
Doing alright
Just about managing
Finding it quite difficult
Finding it very difficult
How would you describe your overall wellbeing at the moment? (Tick One)
Feeling great and thriving
Doing well overall
Managing but with some challenges
Struggling at times
Finding things very difficult
Overall, do you like living within your neighbourhood/community?
Yes
No
I feel like I belong in my neighbourhood/community (Tick One)
Strongly agree
Agree
Neither
Disagree
Strongly disagree
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