Glasgow Helps Referral Form

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1. Welcome to the Glasgow Helps Online Referral Form.
  
  Our online referral form has been designed to ensure we’re able to offer the best support possible from the first conversation, so please take your time and provide us with information that will help us to help you.
  The more detail you provide here, the better we’ll be able to understand what really matters to you, and how we may be able to support.
  If you need any assistance in completing this form then please feel free to give us a call directly on 0141 275 1185 Mon-Fri, 9-5.
  Thank you.
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1. Find out what we do with your data. Read our Privacy Statement
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1. Who are you making this referral for?
  
  Myself
  
  Someone Else
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1. Are you filling out this form with regards to the Early years Establishment campaign?
  
  Yes
  
  No
2. If yes which Establishment (optional)
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1. Which organisation do you work for? For example, Charitable Organisation, HSCP, GCVS, GCC Staff, Other (e.g. family member, staff member of another organisation)? (optional)
2. What is your role within that organisation? (optional)
3. Has the Citizen consented to a referral being made on their behalf? (optional)
  
  Yes
  
  No
4. Your First Name (optional)
5. Your Surname (optional)
6. Your Phone Number (optional)
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1. Citizen Details: First Name
2. Citizen Details: Surname
3. Citizen Details: Date of Birth
4. Gender
  
  Male
  
  Female
  
  Other
  
  Prefer not to say
5. Citizen Details: Contact Phone Number
6. Citizen Details: Email (optional)
7. Citizen Details: Address 1
8. Citizen Details: Address 2 (optional)
9. Citizen Details: Address 3 (optional)
10. Citizen Details: Town/City
11. Citizen Details: Postcode
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1. Do they have a child aged 0 – 5 within their household?
2. Do you have a child aged 0 – 5 within your household?
3. Child under 5
  
  Yes
  
  No
4. What type of support are they looking for from Glasgow Helps?
5. What type of support are you looking for from Glasgow Helps? Please select the issue most important to you right now, and if you need to say more you can do so in the box below.
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  Childcare
  
  Childs Education
  
  Clothing
  
  Culture and Community
  
  Digital Inclusion
  
  Employment
  
  Financial Assistance
  
  Food
  
  Hobbies
  
  Home Essentials
  
  Housing
  
  Internal GCC Query
  
  Mental Health
  
  Physical Health
  
  Public Safety
  
  Transport
  
  Trauma
  
  Utilities/Bill
7. If there's anything else you'd like to tell us, please do so here: (optional)
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1. Is the person being referred a Glasgow City Council employee?
  
  Yes
  
  No
2. What department or area do they work for? (optional)
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1. Do you require assistance, such as an interpreter or sign language?
  
  Yes
  
  No
2. Language spoken (optional)
3. Has the citizen engaged with Glasgow Helps before?
4. Have you spoken with Glasgow Helps before?
5. Yes
  
  No
  
  I Don't Know
6. Do you require assistance, such as an interpreter or sign language? (optional)
  
  Yes
  
  No
7. Language spoken (optional)
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1. If you want to tell us of any supports and services that you may already be receiving or have accessed previously, please do so here (optional)
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1. What supports have you provided the citizen with already? This helps us avoid duplication of effort, so please provide as much detail as possible. (optional)
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1. Any other information (max 4000 characters) (optional)
2. How did you hear about Glasgow Helps? (optional)
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  1. Did you attempt to contact Glasgow Helps over the telephone before completing the online form? (optional)
    
    Yes
    
    No

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Glasgow Helps Referral Form