Move In Move On Referral Form

Move In, Move On Referral Form
Move In, Move On is an initiative run by Vineyard 53.

Moving into an empty property after being homeless, fleeing domestic violence, seeking asylum or moving due to financial hardship can have a significant impact on our mental and physical wellbeing. For those who may already be vulnerable or experiencing mental health concerns, such a move can be even more challenging.

With this in mind, we aim to provide practical support to individuals or families in emergency situations or facing financial hardship.

We are able to purchase items such as kettles, toasters, plates / bowls, cutlery, bins, bedding (duvets, duvet covers), curtains and other small household items. We will also provide a ‘Move in pack’ containing essentials like tea, sugar, washing up bowl, dish towels etc *.

* We are currently unable to help with any white goods or large electrical items.

By providing some of these essentials, our aim is to give people hope that a new start is always possible!

If you are a professional from a statutory agency, housing officer or support worker from a charity and would like to make a referral for someone please use the form below:
SECTION 1 - REFERRAL AGENT CONTACT DETAILS
Date of Referral
Name of Organisation
Name of Referrer
Referrer's Email
Organisation Phone Number
Organisation Address
SECTION 2 - FAMILY DETAILS

Vineyard 53 are happy to make contact with the family/individual to arrange delivery. However, you are not obliged to fill out this section and alternative arrangements can be made to deliver items should you wish to keep details of the recipient confidential. Please note any information given will remain confidential.
Name of Individual
Recipient's Phone Number
Delivery Address
How many family members
Child(ren)'s Gender, Age
Reason for Referral
Item(s) Required
Any Additional Notes/Alternative Arrangements for Delivery
SECTION 3 - EQUAL OPPORTUNITIES

Vineyard 53 Move In Move On believes that no individual or family should be excluded from our activities on the grounds of age, gender, health or disability, sexuality, class, family status, means, ability, colour, ethnic origin, culture, religion or belief. You are not obliged to fill out the Equal Opportunities section, but please note any information given will remain confidential.
Ethnicity of Family
Religion of Family
Any Disabilities?
SECTION 4 - CONSENT

As the referrer please confirm that all information given is accurate to the best of your knowledge and that the individual/family have given consent for this referral. You agree that delivery will be made directly to the recipient unless you have requested alternative arrangements. Please also be aware that all information given will remain confidential and will only be used to provide baseline data for monitoring and evaluation purposes.
Full Name of Referrer
Date
Thank you for completing this referral form, we will endeavour to respond to you within 3 working days.

Please note that whilst most items will be new, some may not be brand new (for example curtains or small items of furniture). All however will be in good working condition.

Please contact Tracey at tracey@vineyard53.org if you have any questions.
Should be Empty:

Move In, Move On Referral Form

SECTION 1 - REFERRAL AGENT CONTACT DETAILS

SECTION 2 - FAMILY DETAILS

SECTION 3 - EQUAL OPPORTUNITIES

SECTION 4 - CONSENT