Make a Referral

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Get Help
What We Do
What You Can Do
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- Newsletters
About Us
Donate

Make a Referral

If you, or someone you know, could use our help, just let us know by completing the form below or give us a call on 0151 207 7617. Alternatively, Click here to email.

Tell us about a rough sleeper

Drop-in advice sessions

We accept referrals from a wide range of agencies as well as self referrals. Simply fill in the form below and one of our team will be in touch to discuss your needs or the client's needs. Please include as much information as possible to help us ensure the appropriate specialist team responds to the referral.
You can complete the form online below or you can download a copy of the form - download referral form

Client Details

* Indicates required field

Name *

Date of birth *

All fields marked * are required

Phone number *

Current address *

Date they moved in *

Ethnic Origin *

Please tell us about your current circumstances by answering the questions below:

Are you homeless, about to be made homeless, or of no fixed abode? *

Yes No

Please provide information about your current housing circumstances in the space below: *

Do you, or have you had, substance use issues? *

Yes No

If "Yes" please provide details of your current and previous substance use in the space below: *

Do you have any mental health issues? *

Yes No

If "Yes" please provide information concerning your mental health in the space below: *

Do you have a history of violence or agression? *

Yes No

If "Yes" please provide information below: *

Note for referring Agents:
Please provide a copy of your most recent risk assessment (email to [email protected]), or alternatively, a summary of the risks you have identified.

Are there any risk issues? *

Yes No Don't Know

Are there any risk issues? Please provide details. It is important that we know of any risks to yourself, to our staff who will be working with you, to others or from others. This will help us decide the most appropriate approach to meet your needs. *

Support Issues: (please indicate all of your support needs)

Choose Any *

Income/Benefits Paying Bills Budgeting Debt Household Tasks Furnishing/ Decorating

Please select as many that apply

Choose Any *

Harassment Neighbour Relations Leisure / daytime activities Nuisance Issues Social Isolation Employment / training

Please select as many that apply

Physical Health Learning Difficulties Offending Education Other

Please provide details of these support needs: *

When is the support needed? (e.g. weekly, daytime, weekends) *

Referrers Details (if applicable)

Agency *

Contact Number *

Referrers Name *

My client is aware of this referral and I have discussed it with them *

Yes No

Email *

Data Processing

Data Processing *

Please tick this box to allow us to hold the data you have supplied for the purpose of processing your application for support. All information will remain confidential and be held securely. Once we begin your support we will discuss and agree with you how we use the data we hold about you and in what circumstances it can be shared. The Data Protection Act 2018 requires that we have your permission to store your personal information. By ticking this box you are agreeing that The Whitechapel Centre will act as data controller of the information you have given us. This will allow us to put your information on our waiting lists. For some services we use the “Merseyside Mainstay Housing and Support Gateway” this database is used by a number of agencies but only those you authorise to view your information.

If you have any queries about how we will store/process your information, please state below. *

Click here to see the list of Mainstay Services who may access your data

Submit

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The Whitechapel Centre
Langsdale Street
Liverpool L3 8DT
Tel: 0151 207 7617

Charity Number: 1013060
Reg Co Number: 2623071

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