Household Support Fund Referral Form

This referral form is available for trusted professionals/practitioners to request support on behalf of the financially vulnerable adults and families that they work with.

Fraudulent referrals will be reported to the Household Support Team at Cheshire East Council who will take appropriate action.

We cover all areas of Cheshire East apart from CW1, CW2, CW3 and CW5.

Referrers details

Date of referral request

Referrers first name

Referrers last name

Referring organisation

Referrer role in organisation

Referrers email address

Referrers contact number

Referral purpose

Client details

Clients first name

Clients last name

Date of birth

Delivery address line 1

Town

Postcode

I have confirmed with the client that this is the correct delivery address, and I understand that providing an incorrect address could result in the order being cancelled.

Clients contact number

Clients email address

Is this referral for a single person or a family?

Items to be requested

Please select the items you wish to request for the client (all new item prices are excluding vat)

Refrigeration (new)

Fridge Freezer - tall (£257)

Fridge - under counter (£176)

Freezer - under counter (£171)

Electrical items (new)

Beds (new)

Furniture (reUse)

Packs

Single bedding pack (inc. single duvet, single bed sheet and pillow slips) (£28)

Double bedding pack (inc. double duvet, double bed sheet, x2 pillows and x2 pillow slips) (£39)

Starter pack (inc. a bowl, dinner plate, knife, fork, desert spoon, tea spoon, mug, glass, bath towel and a hand towel) (£29)

Household pack (inc. 2 piece pan set - large and small with lids, frying pan and a tea towel) (£29)

Additional notes