CLASP Chester Lodging and Support Providers

Please enter details below

Referrer's name and job title

Agency (please choose)
Social Services EP & NBC Housing Dept. Chester and District Housing Trust Connexions CAB Hostel Hospital or CPN GP Surgery Self Others

Telephone contact numbers for referral (office and mobile if available)

Full name of the person you are referring

Date of Birth

Check any of the following that apply?
Mental Health Problems*

Learning disability*

Is the client a young person (aged 16 - 25)?

Is the rent deposit scheme applicable?

Is the client a resident of Ellesmere Port and Neston?

Please supply all relevant information if you have ticked any boxes marked*. If you are not qualified to provide this information please give the name and contact number of a person who is.

All the information you give us will be treated in all possible confidence, will be held on computer and will be covered by the Data Protection Act 1998. Please indicate below to confirm that the information the person you are referring has given and which is written on this form is, to the best of your knowledge, correct, and that you have the subject's signed permission to release this information.

Tick here to agree to the above conditions.