Glasgow City Council
> Glasgow Helps Referral Form

Glasgow Helps Referral Form

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1. Welcome to our Glasgow Helps Online Referral Form.
  
  You can complete this form for yourself or on behalf of someone else. As you answer each question in turn you will be presented with another question and options. Please select the appropriate answer from the ones given for each question. Once completed hit submit and your form will be sent to the team and someone will be in touch to help you get the right support that you need.
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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?
2. 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?
2. Early years*
  
  Yes
  
  No
3. If yes which Establishment
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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)?
2. What is your role within that organisation?
3. Has the Citizen consented to a referral being made on their behalf?
4. Label
  
  Yes
  
  No
5. Your First Name
6. Your Surname
7. Your Phone Number
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1. Citizen Details: First Name*
2. Citizen Details: Surname*
3. Citizen Details: Date of Birth*
4. Gender
5. Label*
  
  Male
  
  Female
  
  Other
  
  Prefer not to say
6. Citizen Details: Contact Phone Number*
7. Citizen Details: Email
8. Citizen Details: Address 1*
9. Citizen Details: Address 2
10. Citizen Details: Address 3
11. Citizen Details: Town/City*
12. Citizen Details: Postcode*
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1. Is the person being referred a Glasgow City Council employee?
2. Are you a Glasgow City Council Employee?*
  
  Yes
  
  No
3. What department or area do they work for?
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1. What support can Glasgow Helps provide?
2. Why is the referral being made? *
  
  Food Support
  
  Help with Money
  
  Mental Health Support
  
  General Health Support
  
  General Advice
  
  Fuel Support/Fuel Advice
  
  Other
3. Do you require assistance, such as an interpreter or sign language?
4. Label*
  
  Yes
  
  No
5. Language spoken
6. Has the citizen engaged with Glasgow Helps before?
7. Have you spoken with Glasgow Helps before?
8. In touch before*
  
  Yes
  
  No
  
  I Don't Know
9. Do you require assistance, such as an interpreter or sign language?
10. help
  
  Yes
  
  No
11. Language spoken
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1. What supports have you provided the citizen with already?
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1. Any other information (max 4000 characters)
2. How did you hear about Glasgow Helps?
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  1. Did you attempt to contact Glasgow Helps over the telephone before completing the online form?
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    Yes
    
    No

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