If you are referring from a Royal Borough of Greenwich council service or one of its commissioned agencies, please send to and

If you are referring from any other organisation, please send to

PLEASE COMPLETE ALL SECTIONS (highlighted yellow)

REFERRAL MADE BY:

Name of referring organisation
Referred by - Name
Email
Contact Number
Relationship of staff to young person (e.g. Support Worker)
Referred from: / Independent Living/Supported Housing / ☐ /
Children’s Services / ☐ /
Housing Services / ☐ /
1st Base (Greenwich only) / ☐ /
Floating Support / ☐ /
Other (please indicate):

Please indicate whether you are referring this young person for a 1 day or 5 day course

Please note that participants should be able to attend all days (Mon-Fri) if being referred to a 5 day course. If this is not possible please let us know.

1 DAY ☐ 5 DAY☐

YOUNG PERSON’S DETAILS:

Name of young person
Young person DOB / Gender (M/F) / Choose an item. /
Young person contact phone number
Email address
Address of young person
Is the young person a social housing tenant?
(If YES, please provide the name of Landlord and which borough they live in) / YES / ☐ / Landlord:
Borough:
NO / ☐ /
Please indicate if young person is ready for Move On / Yes / ☐
No / ☐
Already in a social housing tenancy / ☐
Reason for referral (if known, i.e. rent arrears, debts, problems with benefits, budgeting issues,etc)
Details of any other referrals made related to financial confidence of the young person (e.g. debt advice etc.)
Availability (tick which days resident is available to attend training) / Mon ☐ / Tue ☐ / Wed ☐ / Thu ☐ / Fri ☐
Education /Employment/ Training status
(please indicate) / In full time education/ training / ☐ /
In part time education/ training / ☐ /
In full time employment / ☐ /
In part time employment / ☐ /
Unemployed / NEET / ☐ /
Please indicate if childcare provision is needed (include number of children) / Yes / ☐ / How many children:
Choose an item.
No / ☐ /

For completion by referrer / support staff

further information: In order to help us deliver an excellent standard of training that meets young people’s individual needs please inform us of any special requirements:

Please provide details:
Disability/Learning difficulties
(please provide more details as necessary, e.g. SEN, dyslexia, ADHD, autism, Asperger’s, etc.) / Physical disability / ☐ /
Literacy / ☐ /
Numeracy / ☐ /
Other (please state)
Medical history (complete only if relevant) / Allergies (if yes please indicate below) / ☐ /
Allergy details:
Other (please include any mental health/illness information):
Please provide details:
Significant risks
(please provide more details as necessary) / Drugs / ☐ /
Violence / ☐ /
Gangs (if known indicate gang name) / ☐ /
Safeguarding / ☐ /
Any additional information that may affect your resident’s experience of The Money House should be noted below(e.g. behavioural issues, ESOL, dietary, etc):

YOUNG PERSON PERMISSION TO DISCLOSE INFORMATION TO A THIRD PARTY

Data Protection Act 1998

In order to help you we need to maintain a record of your case, which may contain sensitive personal data. The law says we must get your consent to do this and everything you tell us will be treated confidentially. Sensitive personal data is defined as information relating to any of the following: racial or ethnic origin, political opinions, religious beliefs, trade union membership, health, sexuality or sex life, offences and/or conviction. For the purpose of the act the Data Controller is MyBnk.

I give my consent to be contacted in connection with The Money House via the following communication methods (please indicate):

Email / ☐ / Telephone/ Text / ☐ /

Please indicate if you would be interested in being contacted in connection with The Money House for media opportunities, taking part in user panels and events.

Yes / ☐ / No / ☐ /

I understand that this arrangement may be cancelled at any time.

Signed: / Print Name:
Date: