{"id":32687,"date":"2020-03-18T23:45:09","date_gmt":"2020-03-18T23:45:09","guid":{"rendered":"https:\/\/theparishtrust.org.uk\/ffurflen-gais-am-gymorth-care\/"},"modified":"2026-04-01T09:25:15","modified_gmt":"2026-04-01T08:25:15","slug":"cymorth","status":"publish","type":"page","link":"https:\/\/theparishtrust.org.uk\/cy\/gofal\/cymorth\/","title":{"rendered":"Ffurflen Gais am Gymorth CARE"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"32687\" class=\"elementor elementor-32687 elementor-645\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-2ce515d elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"2ce515d\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;enabled_visibility&quot;:&quot;yes&quot;,&quot;dce_visibility_selected&quot;:&quot;hide&quot;}\">\n\t\t\t\t\t\t<div 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chat&quot;}]},&quot;19&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;10&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;3&quot;,&quot;value&quot;:&quot;To have someone call for a chat&quot;}]},&quot;23&quot;:{&quot;action&quot;:false,&quot;match&quot;:&quot;any&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;10&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;To receive an Essentials Food Parcel&quot;},{&quot;elementId&quot;:&quot;10&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;To receive an Essentials Food Parcel&quot;},{&quot;elementId&quot;:&quot;10&quot;,&quot;operator&quot;:&quot;contains&quot;,&quot;optionId&quot;:null,&quot;value&quot;:&quot;\\&quot;Please Select\\&quot;&quot;}]},&quot;68&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;56&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;I want to request help&quot;},{&quot;elementId&quot;:&quot;58&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;Yes&quot;}]},&quot;78&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;any&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;10&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;To receive an Essentials Food Parcel&quot;}]},&quot;80&quot;:{&quot;action&quot;:true,&quot;match&quot;:&quot;all&quot;,&quot;rules&quot;:[{&quot;elementId&quot;:&quot;77&quot;,&quot;operator&quot;:&quot;eq&quot;,&quot;optionId&quot;:&quot;1&quot;,&quot;value&quot;:&quot;To receive an Essentials Food 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qtip-shadow&quot;,&quot;tooltipMy&quot;:&quot;left center&quot;,&quot;tooltipAt&quot;:&quot;right center&quot;,&quot;isRtl&quot;:false,&quot;scrollOffset&quot;:-50,&quot;scrollSpeed&quot;:800}\"><button class=\"quform-default-submit\" name=\"quform_submit\" type=\"submit\" value=\"submit\" aria-hidden=\"true\" tabindex=\"-1\"><\/button><div class=\"quform-form-inner quform-form-inner-8\"><input type=\"hidden\" name=\"quform_form_id\" value=\"8\" \/><input type=\"hidden\" name=\"quform_form_uid\" value=\"e7cb71\" \/><input type=\"hidden\" name=\"quform_count\" value=\"1\" \/><input type=\"hidden\" name=\"form_url\" value=\"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/pages\/32687\" \/><input type=\"hidden\" name=\"referring_url\" value=\"\" \/><input type=\"hidden\" name=\"post_id\" value=\"\" \/><input type=\"hidden\" name=\"post_title\" value=\"\" \/><input type=\"hidden\" name=\"quform_current_page_id\" value=\"54\" \/><input type=\"hidden\" name=\"quform_loaded\" value=\"1776830059|717da781d3ac5034d814467e47b88538\" \/><input type=\"hidden\" name=\"quform_csrf_token\" value=\"jEV7HjZOJ4tI5o13dqMY7kNkNwjXLFB5mc70j0UT\" \/><div class=\"quform-form-title-description\"><h1 class=\"quform-form-title\">CARE Support Request Form<\/h1><\/div><div class=\"quform-elements quform-elements-8 quform-cf quform-responsive-elements-phone-landscape\"><div class=\"quform-element quform-element-page quform-page-54 quform-page-8_54 quform-cf quform-group-style-plain quform-first-page quform-current-page\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-radio quform-element-8_56 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_56\"><label class=\"quform-label-text\" id=\"quform_8_56_e7cb71_label\">Do you want to request help or make a referral for help on behalf of someone else?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-8_56\"><div class=\"quform-input quform-input-radio quform-input-8_56 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_8_56_e7cb71_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_8_56\" id=\"quform_8_56_e7cb71_1\" class=\"quform-field quform-field-radio quform-field-8_56 quform-field-8_56_1\" value=\"I want to request help\" \/><label for=\"quform_8_56_e7cb71_1\" class=\"quform-option-label quform-option-label-8_56_1\"><span class=\"quform-option-text\">I want to request help<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_8_56\" id=\"quform_8_56_e7cb71_2\" class=\"quform-field quform-field-radio quform-field-8_56 quform-field-8_56_2\" value=\"I want to refer someone for help\" \/><label for=\"quform_8_56_e7cb71_2\" class=\"quform-option-label quform-option-label-8_56_2\"><span class=\"quform-option-text\">I want to refer someone for help<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-8_146 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_146\"><label class=\"quform-label-text\" for=\"quform_8_146_e7cb71\">Please enter your password<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_146\"><p class=\"quform-description quform-description-above\">Passwords are case sensitive.<\/p><div class=\"quform-input quform-input-text quform-input-8_146 quform-cf\"><input type=\"text\" id=\"quform_8_146_e7cb71\" name=\"quform_8_146\" class=\"quform-field quform-field-text quform-field-8_146\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-8_58 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_58\"><label class=\"quform-label-text\" id=\"quform_8_58_e7cb71_label\">Do you have a referral number?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-8_58\"><p class=\"quform-description quform-description-above\"><b>Please ensure you select the correct option.<\/b> Failure to do so will invalidate your request and it will not be processed. A referral number starts with <b><\/i>R-<\/b><\/i> followed by a 7 digit number.<\/p><div class=\"quform-input quform-input-radio quform-input-8_58 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_8_58_e7cb71_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_8_58\" id=\"quform_8_58_e7cb71_1\" class=\"quform-field quform-field-radio quform-field-8_58 quform-field-8_58_1\" value=\"Yes\" \/><label for=\"quform_8_58_e7cb71_1\" class=\"quform-option-label quform-option-label-8_58_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_8_58\" id=\"quform_8_58_e7cb71_4\" class=\"quform-field quform-field-radio quform-field-8_58 quform-field-8_58_4\" value=\"No\" \/><label for=\"quform_8_58_e7cb71_4\" class=\"quform-option-label quform-option-label-8_58_4\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-8_61 quform-cf\"><div class=\"quform-spacer\">That's not a problem... we can still help you! If you are requesting pastoral care, please ignore this message and continue with your request.<br><br>\n\n<strong>If you're requesting a food parcel, the process is slightly different...<\/strong><br><br>\n\nWe can give you up to three food parcels in a calendar year (between January and December each year) without a referral number.<br><br>\n\nIf you need more food parcels after this, you will need to get a referral from one of our partners.<br><br>\n\nGetting a referral number is easy and straight forward, and will enable you to have ongoing support for 90 days, where you can request a food parcel each week, full of cupboard food, fridge food, and frozen food.<br><br>\n\nThere are lots of people who can refer you, from schools, to health visitors, social services, to support workers. If your situation still hasn't improved after 90 days, you can be referred again.<br><br>\n\nTo find out more about who our referral partners are and how to get a referral, <a href=\"https:\/\/theparishtrust.org.uk\/care#Referrals\" target=\"_blank\" rel=\"noopener\">please click here.<\/a><\/div><\/div><div class=\"quform-element quform-element-text quform-element-8_60 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_60\"><label class=\"quform-label-text\" for=\"quform_8_60_e7cb71\">What is your referral number?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_60\"><p class=\"quform-description quform-description-above\">This number must match our records exactly, otherwise we will be unable to help you. Please only put your <b>7 digit number<\/b> in this field.<\/p><div class=\"quform-input quform-input-text quform-input-8_60 quform-cf\"><input type=\"text\" id=\"quform_8_60_e7cb71\" name=\"quform_8_60\" class=\"quform-field quform-field-text quform-field-8_60\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-8_55 quform-cf quform-button-style-theme\"><div class=\"quform-button-next quform-button-next-default quform-button-next-8_55\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Next<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-1 quform-page-8_1 quform-cf quform-group-style-plain\"><div class=\"quform-page-title-description\"><h3 class=\"quform-page-title\">Temporary Assistance Request<\/h3><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-group quform-element-8_8 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Your Details<\/h4><p class=\"quform-group-description\">Please ensure that these details are filled in <b>accurately<\/b>. Thank you.<\/p><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-name quform-element-8_5 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_5\"><label class=\"quform-label-text\" id=\"quform_8_5_e7cb71_label\">Name<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-name quform-inner-8_5\"><div class=\"quform-input quform-input-name quform-input-8_5 quform-cf\"><div class=\"quform-element-row quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element-column\"><div class=\"quform-element quform-element-text quform-element-8_5_2 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-text quform-inner-8_5_2\"><div class=\"quform-input quform-input-text quform-input-8_5_2 quform-cf\"><input type=\"text\" id=\"quform_8_5_2_e7cb71\" name=\"quform_8_5[2]\" class=\"quform-field quform-field-text quform-field-8_5_2\" placeholder=\"First\" aria-labelledby=\"quform_8_5_e7cb71_label\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element-column\"><div class=\"quform-element quform-element-text quform-element-8_5_4 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-text quform-inner-8_5_4\"><div class=\"quform-input quform-input-text quform-input-8_5_4 quform-cf\"><input type=\"text\" id=\"quform_8_5_4_e7cb71\" name=\"quform_8_5[4]\" class=\"quform-field quform-field-text quform-field-8_5_4\" placeholder=\"Last\" aria-labelledby=\"quform_8_5_e7cb71_label\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-8_6 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_6\"><label class=\"quform-label-text\" for=\"quform_8_6_e7cb71\">Telephone Number<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_6\"><div class=\"quform-input quform-input-text quform-input-8_6 quform-cf\"><input type=\"text\" id=\"quform_8_6_e7cb71\" name=\"quform_8_6\" class=\"quform-field quform-field-text quform-field-8_6\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-8_180 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_180\"><label class=\"quform-label-text\" for=\"quform_8_180_e7cb71\">House Number<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_180\"><div class=\"quform-input quform-input-text quform-input-8_180 quform-cf\"><input type=\"text\" id=\"quform_8_180_e7cb71\" name=\"quform_8_180\" class=\"quform-field quform-field-text quform-field-8_180\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-select quform-element-8_181 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_181\"><label class=\"quform-label-text\" for=\"quform_8_181_e7cb71\">Is this number for a house, or a flat?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-8_181\"><div class=\"quform-input quform-input-select quform-input-8_181 quform-cf\"><select id=\"quform_8_181_e7cb71\" name=\"quform_8_181\" class=\"quform-field quform-field-select quform-field-8_181\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"House\">House<\/option><option value=\"Flat\">Flat<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-8_7 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_7\"><label class=\"quform-label-text\" for=\"quform_8_7_e7cb71\">Address<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-8_7\"><div class=\"quform-input quform-input-textarea quform-input-8_7 quform-cf\"><textarea id=\"quform_8_7_e7cb71\" name=\"quform_8_7\" class=\"quform-field quform-field-textarea quform-field-8_7\"><\/textarea><\/div><p class=\"quform-description quform-description-below\">Enter your full address (including the house\/flat number again)<\/p><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-8_49 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_49\"><label class=\"quform-label-text\" for=\"quform_8_49_e7cb71\">Postcode<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_49\"><div class=\"quform-input quform-input-text quform-input-8_49 quform-cf\"><input type=\"text\" id=\"quform_8_49_e7cb71\" name=\"quform_8_49\" class=\"quform-field quform-field-text quform-field-8_49\" \/><\/div><p class=\"quform-description quform-description-below\">Enter your post code with no spaces. We will only help service users within the CF83 postcode area.<\/p><\/div><\/div><\/div><div class=\"quform-element quform-element-email quform-element-8_4 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_4\"><label class=\"quform-label-text\" for=\"quform_8_4_e7cb71\">Email address<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-email quform-inner-8_4\"><div class=\"quform-input quform-input-email quform-input-8_4 quform-cf\"><input type=\"email\" id=\"quform_8_4_e7cb71\" name=\"quform_8_4\" class=\"quform-field quform-field-email quform-field-8_4\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-email quform-element-8_48 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_48\"><label class=\"quform-label-text\" for=\"quform_8_48_e7cb71\">Confirm Email address<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-email quform-inner-8_48\"><div class=\"quform-input quform-input-email quform-input-8_48 quform-cf\"><input type=\"email\" id=\"quform_8_48_e7cb71\" name=\"quform_8_48\" class=\"quform-field quform-field-email quform-field-8_48\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-select quform-element-8_42 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_42\"><label class=\"quform-label-text\" for=\"quform_8_42_e7cb71\">Please confirm that you live in an area covered by the CARE Project:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-8_42\"><div class=\"quform-input quform-input-select quform-input-8_42 quform-cf\"><select id=\"quform_8_42_e7cb71\" name=\"quform_8_42\" class=\"quform-field quform-field-select quform-field-8_42\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"Bedwas\">Bedwas<\/option><option value=\"Trethomas\">Trethomas<\/option><option value=\"Graig-y-Rhacca\">Graig-y-Rhacca<\/option><option value=\"Machen\">Machen<\/option><option value=\"Lower Machen\">Lower Machen<\/option><option value=\"Draethen\">Draethen<\/option><option value=\"Waterloo\">Waterloo<\/option><option value=\"Rudry\">Rudry<\/option><option value=\"Michaelston-y-Fedw\">Michaelston-y-Fedw<\/option><option value=\"Cefn Mably\">Cefn Mably<\/option><option value=\"Caerphilly Town Centre\">Caerphilly Town Centre<\/option><option value=\"Lansbury Park\">Lansbury Park<\/option><option value=\"Mornington Meadows\">Mornington Meadows<\/option><option value=\"Castle Park\">Castle Park<\/option><option value=\"Wernddu\">Wernddu<\/option><option value=\"Trecenydd\">Trecenydd<\/option><option value=\"Energlyn\">Energlyn<\/option><option value=\"Penyrheol\">Penyrheol<\/option><option value=\"Llanbradach\">Llanbradach<\/option><option value=\"Senghenydd\">Senghenydd<\/option><option value=\"Abertridwr\">Abertridwr<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-select quform-element-8_10 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_10\"><label class=\"quform-label-text\" for=\"quform_8_10_e7cb71\">What is the request?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-8_10\"><div class=\"quform-input quform-input-select quform-input-8_10 quform-cf\"><select id=\"quform_8_10_e7cb71\" name=\"quform_8_10\" class=\"quform-field quform-field-select quform-field-8_10\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"To receive an Essentials Food Parcel\">To receive an Essentials Food Parcel<\/option><option value=\"To have someone call for a chat\">To have someone call for a chat<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-8_53 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_53\"><label class=\"quform-label-text\" id=\"quform_8_53_e7cb71_label\">Please confirm that you are in genuine need of assistance<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-8_53\"><p class=\"quform-description quform-description-above\">The CARE Project is here to help anyone who is in genuine need. This means that if you have help available to you in the form of family\/friends to get food\/prescriptions\/click and collect deliveries, or you have the financial means to buy your own food, we are not able to help you.<\/p><div class=\"quform-input quform-input-checkbox quform-input-8_53 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_8_53_e7cb71_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_8_53[]\" id=\"quform_8_53_e7cb71_1\" class=\"quform-field quform-field-checkbox quform-field-8_53 quform-field-8_53_1\" value=\"I confirm\" \/><label for=\"quform_8_53_e7cb71_1\" class=\"quform-option-label quform-option-label-8_53_1\"><span class=\"quform-option-text\">I confirm<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-select quform-element-8_38 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_38\"><label class=\"quform-label-text\" for=\"quform_8_38_e7cb71\">Why are you in need of assistance?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-8_38\"><div class=\"quform-input quform-input-select quform-input-8_38 quform-cf\"><select id=\"quform_8_38_e7cb71\" name=\"quform_8_38\" class=\"quform-field quform-field-select quform-field-8_38\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"Unemployed\">Unemployed<\/option><option value=\"Benefit Changes \/ Delays\">Benefit Changes \/ Delays<\/option><option value=\"Debt\">Debt<\/option><option value=\"Child Holiday Meals\">Child Holiday Meals<\/option><option value=\"Delayed Wages\">Delayed Wages<\/option><option value=\"Domestic Abuse\">Domestic Abuse<\/option><option value=\"Sickness \/ Ill Health\">Sickness \/ Ill Health<\/option><option value=\"No recourse of Public Funds\">No recourse of Public Funds<\/option><option value=\"Housebound\">Housebound<\/option><option value=\"Pensioner Poverty\">Pensioner Poverty<\/option><option value=\"Poor Mental Health\">Poor Mental Health<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-8_9 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Your Request<\/h4><p class=\"quform-group-description\">Your food parcel will be made up of food donated by businesses, supermarkets and other charitable enterprises. Some food contained in your parcel may be beyond it's \"Best Before\" date, and some food may be frozen prior to its \"Use By\" date. Food that is past its \"Best Before\" date is <b>still edible<\/b>.\n\nWe will endeavour to ensure that food allergens are labelled where appropriate, but we cannot guarantee that there has been no cross-contamination during the decanting, sorting and preparing of foods.\n\nBy continuing with this request, you are agreeing that you understand this, and that any food you accept from us becomes your responsibility on transfer.<\/p><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-text quform-element-8_13 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_13\"><label class=\"quform-label-text\" for=\"quform_8_13_e7cb71\">Number of Adults in household?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_13\"><div class=\"quform-input quform-input-text quform-input-8_13 quform-cf\"><input type=\"text\" id=\"quform_8_13_e7cb71\" name=\"quform_8_13\" class=\"quform-field quform-field-text quform-field-8_13\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-8_14 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_14\"><label class=\"quform-label-text\" for=\"quform_8_14_e7cb71\">Number of Children in household?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_14\"><div class=\"quform-input quform-input-text quform-input-8_14 quform-cf\"><input type=\"text\" id=\"quform_8_14_e7cb71\" name=\"quform_8_14\" class=\"quform-field quform-field-text quform-field-8_14\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-8_15 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_15\"><label class=\"quform-label-text\" for=\"quform_8_15_e7cb71\">Tailoring your request<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-8_15\"><p class=\"quform-description quform-description-above\">Please let us know if anyone in your household has any dietary requirements, or whether there are any particular items you desperately need or don't need <i> Please remember: food is donated to us, so we cannot guarantee stock of any particular item. Also, delivery drivers will not take unwanted food back with them once it has been delivered to you.<\/i><\/p><div class=\"quform-input quform-input-textarea quform-input-8_15 quform-cf\"><textarea id=\"quform_8_15_e7cb71\" name=\"quform_8_15\" class=\"quform-field quform-field-textarea quform-field-8_15\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-8_16 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_16\"><label class=\"quform-label-text\" for=\"quform_8_16_e7cb71\">Do you need any essential non-food items?<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-8_16\"><p class=\"quform-description quform-description-above\">e.g Toothpaste, Soap, Toilet Roll, Sanitary products. We DO NOT supply clothes or pet food. Please remember that we CANNOT guarantee that these items will be available when we compile your food parcel.<\/p><div class=\"quform-input quform-input-textarea quform-input-8_16 quform-cf\"><textarea id=\"quform_8_16_e7cb71\" name=\"quform_8_16\" class=\"quform-field quform-field-textarea quform-field-8_16\"><\/textarea><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-8_17 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-child-elements\"><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-8_19 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Your Request: A Telephone Call<\/h4><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-textarea quform-element-8_20 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_20\"><label class=\"quform-label-text\" for=\"quform_8_20_e7cb71\">Is there anything we need to know?<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-8_20\"><p class=\"quform-description quform-description-above\">We want to allocate a volunteer that is suited to your needs. If you need to talk about something specific, please let us know in this box. It may also be helpful to know a little bit about you, your age, and your interests. This may mean that we are able to connect you with other people in the community. However, please don't feel you need to fill this box in!<\/p><div class=\"quform-input quform-input-textarea quform-input-8_20 quform-cf\"><textarea id=\"quform_8_20_e7cb71\" name=\"quform_8_20\" class=\"quform-field quform-field-textarea quform-field-8_20\"><\/textarea><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-8_2 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-8_2\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Back<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-8_2\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Next<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-68 quform-page-8_68 quform-cf quform-group-style-plain\"><div class=\"quform-page-title-description\"><h3 class=\"quform-page-title\">Referred Assistance Request<\/h3><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-group quform-element-8_69 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Service User Details<\/h4><p class=\"quform-group-description\">Please ensure that these details match your referral details <b>exactly<\/b>. You CANNOT put in a request for someone else.<\/p><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-name quform-element-8_70 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_70\"><label class=\"quform-label-text\" id=\"quform_8_70_e7cb71_label\">Name<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-name quform-inner-8_70\"><div class=\"quform-input quform-input-name quform-input-8_70 quform-cf\"><div class=\"quform-element-row quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element-column\"><div class=\"quform-element quform-element-text quform-element-8_70_2 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-text quform-inner-8_70_2\"><div class=\"quform-input quform-input-text quform-input-8_70_2 quform-cf\"><input type=\"text\" id=\"quform_8_70_2_e7cb71\" name=\"quform_8_70[2]\" class=\"quform-field quform-field-text quform-field-8_70_2\" placeholder=\"First\" aria-labelledby=\"quform_8_70_e7cb71_label\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element-column\"><div class=\"quform-element quform-element-text quform-element-8_70_4 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-text quform-inner-8_70_4\"><div class=\"quform-input quform-input-text quform-input-8_70_4 quform-cf\"><input type=\"text\" id=\"quform_8_70_4_e7cb71\" name=\"quform_8_70[4]\" class=\"quform-field quform-field-text quform-field-8_70_4\" placeholder=\"Last\" aria-labelledby=\"quform_8_70_e7cb71_label\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-8_71 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_71\"><label class=\"quform-label-text\" for=\"quform_8_71_e7cb71\">Telephone Number<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_71\"><div class=\"quform-input quform-input-text quform-input-8_71 quform-cf\"><input type=\"text\" id=\"quform_8_71_e7cb71\" name=\"quform_8_71\" class=\"quform-field quform-field-text quform-field-8_71\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-email quform-element-8_75 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_75\"><label class=\"quform-label-text\" for=\"quform_8_75_e7cb71\">Email address<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-email quform-inner-8_75\"><div class=\"quform-input quform-input-email quform-input-8_75 quform-cf\"><input type=\"email\" id=\"quform_8_75_e7cb71\" name=\"quform_8_75\" class=\"quform-field quform-field-email quform-field-8_75\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-email quform-element-8_76 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_76\"><label class=\"quform-label-text\" for=\"quform_8_76_e7cb71\">Confirm Email address<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-email quform-inner-8_76\"><div class=\"quform-input quform-input-email quform-input-8_76 quform-cf\"><input type=\"email\" id=\"quform_8_76_e7cb71\" name=\"quform_8_76\" class=\"quform-field quform-field-email quform-field-8_76\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-8_177 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_177\"><label class=\"quform-label-text\" for=\"quform_8_177_e7cb71\">House Number<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_177\"><div class=\"quform-input quform-input-text quform-input-8_177 quform-cf\"><input type=\"text\" id=\"quform_8_177_e7cb71\" name=\"quform_8_177\" class=\"quform-field quform-field-text quform-field-8_177\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-select quform-element-8_178 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_178\"><label class=\"quform-label-text\" for=\"quform_8_178_e7cb71\">Is this number for a house, or a flat?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-8_178\"><div class=\"quform-input quform-input-select quform-input-8_178 quform-cf\"><select id=\"quform_8_178_e7cb71\" name=\"quform_8_178\" class=\"quform-field quform-field-select quform-field-8_178\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"House\">House<\/option><option value=\"Flat \/ Apartment\">Flat \/ Apartment<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-8_148 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_148\"><label class=\"quform-label-text\" for=\"quform_8_148_e7cb71\">Address<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-8_148\"><p class=\"quform-description quform-description-above\">This address must match the address on your referral record.<\/p><div class=\"quform-input quform-input-textarea quform-input-8_148 quform-cf\"><textarea id=\"quform_8_148_e7cb71\" name=\"quform_8_148\" class=\"quform-field quform-field-textarea quform-field-8_148\"><\/textarea><\/div><p class=\"quform-description quform-description-below\">Enter your full address (including the house\/flat number again)<\/p><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-8_149 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_149\"><label class=\"quform-label-text\" for=\"quform_8_149_e7cb71\">Postcode<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_149\"><div class=\"quform-input quform-input-text quform-input-8_149 quform-cf\"><input type=\"text\" id=\"quform_8_149_e7cb71\" name=\"quform_8_149\" class=\"quform-field quform-field-text quform-field-8_149\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-select quform-element-8_77 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_77\"><label class=\"quform-label-text\" for=\"quform_8_77_e7cb71\">What is the request?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-8_77\"><div class=\"quform-input quform-input-select quform-input-8_77 quform-cf\"><select id=\"quform_8_77_e7cb71\" name=\"quform_8_77\" class=\"quform-field quform-field-select quform-field-8_77\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"To receive an Essentials Food Parcel\">To receive an Essentials Food Parcel<\/option><option value=\"To have someone call for a chat\">To have someone call for a chat<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-8_78 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_78\"><label class=\"quform-label-text\" id=\"quform_8_78_e7cb71_label\">Please confirm that you are in genuine need of assistance<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-8_78\"><p class=\"quform-description quform-description-above\">The CARE Project is here to help anyone who is in genuine need. This means that if you have help available to you in the form of family\/friends to get food\/prescriptions\/click and collect deliveries, or you have the financial means to buy your own food, we are not able to help you.<\/p><div class=\"quform-input quform-input-checkbox quform-input-8_78 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_8_78_e7cb71_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_8_78[]\" id=\"quform_8_78_e7cb71_1\" class=\"quform-field quform-field-checkbox quform-field-8_78 quform-field-8_78_1\" value=\"I confirm\" \/><label for=\"quform_8_78_e7cb71_1\" class=\"quform-option-label quform-option-label-8_78_1\"><span class=\"quform-option-text\">I confirm<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-8_80 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Your Request: Essentials Food Parcel<\/h4><p class=\"quform-group-description\">Your food parcel will be made up of food donated by individuals, businesses, supermarkets and other charitable enterprises. Some food contained in your parcel may be beyond it's \"Best Before\" date, and some food may be frozen prior to its \"Use By\" date. Food that is past its \"Best Before\" date is <b>still edible<\/b>.\n\nWe will endeavour to ensure that food allergens are labelled where appropriate, but we cannot guarantee that there has been no cross-contamination during the decanting, sorting and preparing of foods.\n\nBy continuing with this request, you are agreeing that you understand this, and that any food you accept from us becomes your responsibility on transfer.<\/p><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-text quform-element-8_81 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_81\"><label class=\"quform-label-text\" for=\"quform_8_81_e7cb71\">Number of Adults in household?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_81\"><div class=\"quform-input quform-input-text quform-input-8_81 quform-cf\"><input type=\"text\" id=\"quform_8_81_e7cb71\" name=\"quform_8_81\" class=\"quform-field quform-field-text quform-field-8_81\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-8_82 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_82\"><label class=\"quform-label-text\" for=\"quform_8_82_e7cb71\">Number of Children in household?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_82\"><div class=\"quform-input quform-input-text quform-input-8_82 quform-cf\"><input type=\"text\" id=\"quform_8_82_e7cb71\" name=\"quform_8_82\" class=\"quform-field quform-field-text quform-field-8_82\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-8_83 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_83\"><label class=\"quform-label-text\" for=\"quform_8_83_e7cb71\">Tailoring your request<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-8_83\"><p class=\"quform-description quform-description-above\">Please let us know if anyone in your household has any dietary requirements, or whether there are any particular items you desperately need or don't need <i> Please remember: food is donated to us, so we cannot guarantee stock of any particular item. Also, delivery drivers will not take unwanted food back with them once it has been delivered to you.<\/i><\/p><div class=\"quform-input quform-input-textarea quform-input-8_83 quform-cf\"><textarea id=\"quform_8_83_e7cb71\" name=\"quform_8_83\" class=\"quform-field quform-field-textarea quform-field-8_83\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-8_84 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_84\"><label class=\"quform-label-text\" for=\"quform_8_84_e7cb71\">Do you need any essential non-food items?<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-8_84\"><p class=\"quform-description quform-description-above\">e.g Toothpaste, Soap, Toilet Roll, Sanitary products. We DO NOT supply clothes or pet food. Please remember that we CANNOT guarantee that these items will be available when we compile your food parcel.<\/p><div class=\"quform-input quform-input-textarea quform-input-8_84 quform-cf\"><textarea id=\"quform_8_84_e7cb71\" name=\"quform_8_84\" class=\"quform-field quform-field-textarea quform-field-8_84\"><\/textarea><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-8_86 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Your Request: A Telephone Call<\/h4><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-textarea quform-element-8_87 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_87\"><label class=\"quform-label-text\" for=\"quform_8_87_e7cb71\">Is there anything we need to know?<\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-8_87\"><p class=\"quform-description quform-description-above\">We want to allocate a volunteer that is suited to your needs. If you need to talk about something specific, please let us know in this box. It may also be helpful to know a little bit about you, your age, and your interests. This may mean that we are able to connect you with other people in the community. However, please don't feel you need to fill this box in!<\/p><div class=\"quform-input quform-input-textarea quform-input-8_87 quform-cf\"><textarea id=\"quform_8_87_e7cb71\" name=\"quform_8_87\" class=\"quform-field quform-field-textarea quform-field-8_87\"><\/textarea><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-8_156 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-8_156\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Back<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-8_156\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Next<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-96 quform-page-8_96 quform-cf quform-group-style-plain\"><div class=\"quform-page-title-description\"><h3 class=\"quform-page-title\">Referral Form<\/h3><p class=\"quform-page-description\">As a referral partner, you are able to refer an individual\/family to us for assistance. This assistance will last <b>90 days<\/b>, at which point we hope that the individual or family concerned will have found a permanent solution to their crisis. If this is not the case, you may refer them again after meeting them to discuss their ongoing needs and assessing them.<\/p><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-group quform-element-8_171 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-8_173 quform-cf\"><div class=\"quform-spacer\"><h3><em><strong>Important information from October 2025<\/strong><\/em><\/h3><br \/>\nDear Referral Partner,<br \/>\n<br \/>\nWe now require referrals to contain more information about the reason behind the request for support. We are actively seeking as a charity to create pathways out of poverty and as such there will be additional questions for you to answer in consultation with the Service User.<br \/>\n<br \/>\nWe have now removed the option for referral partners to select \"Low Income\/Wages\" as the reason for support as this does not necessarily constitute a genuine need for support from the CARE Project, and is vague in description.<\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-8_174 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_174\"><label class=\"quform-label-text\" id=\"quform_8_174_e7cb71_label\">I confirm that I have read, understood, and will abide by the above.<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-8_174\"><div class=\"quform-input quform-input-checkbox quform-input-8_174 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_8_174_e7cb71_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_8_174[]\" id=\"quform_8_174_e7cb71_1\" class=\"quform-field quform-field-checkbox quform-field-8_174 quform-field-8_174_1\" value=\"Please tick\" \/><label for=\"quform_8_174_e7cb71_1\" class=\"quform-option-label quform-option-label-8_174_1\"><span class=\"quform-option-text\">Please tick<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-8_175 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_175\"><label class=\"quform-label-text\" id=\"quform_8_175_e7cb71_label\">Gathering Data<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-8_175\"><p class=\"quform-description quform-description-above\">The Parish Trust CARE Project will need to gather data about the Service User in order to provide the best service possible, and to report statistics to regulatory bodies and grant funders. We need the Service User's understanding and consent that we will be in contact with the Service User to ask about their circumstances and how we can help them. We will not be able to offer our help without this consent.<\/p><div class=\"quform-input quform-input-checkbox quform-input-8_175 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_8_175_e7cb71_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_8_175[]\" id=\"quform_8_175_e7cb71_1\" class=\"quform-field quform-field-checkbox quform-field-8_175 quform-field-8_175_1\" value=\"The Service User consents\" \/><label for=\"quform_8_175_e7cb71_1\" class=\"quform-option-label quform-option-label-8_175_1\"><span class=\"quform-option-text\">The Service User consents<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-8_97 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Referrer Details<\/h4><p class=\"quform-group-description\">Please ensure that these details are filled in <b>accurately<\/b>. Thank you.<\/p><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-name quform-element-8_98 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_98\"><label class=\"quform-label-text\" id=\"quform_8_98_e7cb71_label\">Your Name<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-name quform-inner-8_98\"><div class=\"quform-input quform-input-name quform-input-8_98 quform-cf\"><div class=\"quform-element-row quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element-column\"><div class=\"quform-element quform-element-text quform-element-8_98_2 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-text quform-inner-8_98_2\"><div class=\"quform-input quform-input-text quform-input-8_98_2 quform-cf\"><input type=\"text\" id=\"quform_8_98_2_e7cb71\" name=\"quform_8_98[2]\" class=\"quform-field quform-field-text quform-field-8_98_2\" placeholder=\"First\" aria-labelledby=\"quform_8_98_e7cb71_label\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element-column\"><div class=\"quform-element quform-element-text quform-element-8_98_4 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-text quform-inner-8_98_4\"><div class=\"quform-input quform-input-text quform-input-8_98_4 quform-cf\"><input type=\"text\" id=\"quform_8_98_4_e7cb71\" name=\"quform_8_98[4]\" class=\"quform-field quform-field-text quform-field-8_98_4\" placeholder=\"Last\" aria-labelledby=\"quform_8_98_e7cb71_label\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-8_99 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_99\"><label class=\"quform-label-text\" for=\"quform_8_99_e7cb71\">Telephone Number<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_99\"><div class=\"quform-input quform-input-text quform-input-8_99 quform-cf\"><input type=\"text\" id=\"quform_8_99_e7cb71\" name=\"quform_8_99\" class=\"quform-field quform-field-text quform-field-8_99\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-email quform-element-8_102 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_102\"><label class=\"quform-label-text\" for=\"quform_8_102_e7cb71\">Email address<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-email quform-inner-8_102\"><div class=\"quform-input quform-input-email quform-input-8_102 quform-cf\"><input type=\"email\" id=\"quform_8_102_e7cb71\" name=\"quform_8_102\" class=\"quform-field quform-field-email quform-field-8_102\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-email quform-element-8_103 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_103\"><label class=\"quform-label-text\" for=\"quform_8_103_e7cb71\">Confirm Email address<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-email quform-inner-8_103\"><div class=\"quform-input quform-input-email quform-input-8_103 quform-cf\"><input type=\"email\" id=\"quform_8_103_e7cb71\" name=\"quform_8_103\" class=\"quform-field quform-field-email quform-field-8_103\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-8_133 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_133\"><label class=\"quform-label-text\" for=\"quform_8_133_e7cb71\">Name of Referral Partner<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_133\"><p class=\"quform-description quform-description-above\">This will be the name of the organisation you work for.<\/p><div class=\"quform-input quform-input-text quform-input-8_133 quform-cf\"><input type=\"text\" id=\"quform_8_133_e7cb71\" name=\"quform_8_133\" class=\"quform-field quform-field-text quform-field-8_133\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-select quform-element-8_134 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_134\"><label class=\"quform-label-text\" for=\"quform_8_134_e7cb71\">What type of organisation do you represent?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-8_134\"><div class=\"quform-input quform-input-select quform-input-8_134 quform-cf\"><select id=\"quform_8_134_e7cb71\" name=\"quform_8_134\" class=\"quform-field quform-field-select quform-field-8_134\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"GP \/ Medical Establishment\">GP \/ Medical Establishment<\/option><option value=\"School \/ Education Establishment\">School \/ Education Establishment<\/option><option value=\"Social Services\">Social Services<\/option><option value=\"Public\/Emergency Service\">Public\/Emergency Service<\/option><option value=\"Church or other Religious Establishment\">Church or other Religious Establishment<\/option><option value=\"Housing Association \/ Organisation\">Housing Association \/ Organisation<\/option><option value=\"Job Centre\">Job Centre<\/option><option value=\"Citizens Advice\">Citizens Advice<\/option><option value=\"Charity\">Charity<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-8_136 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Eligibility<\/h4><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-html quform-element-8_167 quform-cf\"><div class=\"quform-spacer\">This section helps us to understand the Service User's needs. Before you continue with the form, you are required to understand the following:\n\n<strong>Location of the Service User:\u00a0<\/strong>Service Users must reside in an area we cover. They cannot claim help from us via another address such as a family member or friend.\n\n<strong>Service User's Reason for Requesting Help:\u00a0<\/strong>Service Users need to tell you why they have made the decision to seek to be referred to us. You can choose from one of the following options:\n<ul>\n \t<li>Unemployed -\u00a0<em>Service User has been made redundant, or is seeking employment but has been unsuccessful thus far.<\/em><\/li>\n \t<li>Benefit Changes \/ Delays -\u00a0<em>A change in circumstance means that benefit has been claimed or changed, and there is a delay in them coming through to the Service User's bank account<\/em><\/li>\n \t<li>Debt -\u00a0<em>The Service User has debt of any kind, including credit cards and other short term debt such as overdraft\/pay day loans.<\/em><\/li>\n \t<li>Child Holiday Meals -\u00a0<em>Service User already claims free school meals and will find it a struggle to provide food through the school holidays<\/em><\/li>\n \t<li>Delayed Wages -\u00a0<em>Service Users are recently employed or who are self-employed\/paid by invoice<\/em><\/li>\n \t<li>Domestic Abuse -\u00a0<em>Any victim of domestic abuse<\/em><\/li>\n \t<li>Sickness \/ Ill Health -\u00a0<em>Any Service User who is ill for an extended period, has a highly infectious disease, or who has been declared unfit to work.<\/em><\/li>\n \t<li>No recourse of Public Funds -\u00a0<em>Service User who is claiming Assylum<\/em><\/li>\n \t<li>Housebound -\u00a0<em>Any Service User who is physically unable to go out of the house.<\/em><\/li>\n \t<li>Pensioner Poverty -\u00a0<em>Service Users in receipt of a STATE pension that does not cover the cost of living (private pensions do not qualify).<\/em><\/li>\n \t<li>Poor Mental Health - <em>Service User who is suffering from difficult experiences affecting their wellbeing<\/em><\/li>\n<\/ul><\/div><\/div><div class=\"quform-element quform-element-checkbox quform-element-8_169 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_169\"><label class=\"quform-label-text\" id=\"quform_8_169_e7cb71_label\">Please confirm that you understand this eligibility criteria and will select appropriate answers in the following eligibility questions.<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-8_169\"><div class=\"quform-input quform-input-checkbox quform-input-8_169 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_8_169_e7cb71_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_8_169[]\" id=\"quform_8_169_e7cb71_1\" class=\"quform-field quform-field-checkbox quform-field-8_169 quform-field-8_169_1\" value=\"I understand\" \/><label for=\"quform_8_169_e7cb71_1\" class=\"quform-option-label quform-option-label-8_169_1\"><span class=\"quform-option-text\">I understand<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-8_168 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-select quform-element-8_131 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_131\"><label class=\"quform-label-text\" for=\"quform_8_131_e7cb71\">Please confirm that the Service User lives in an area covered by the CARE Project:<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-8_131\"><p class=\"quform-description quform-description-above\">We cover areas in the following post codes: CF83, CF3 6, NP10 8. If the service user does not fall into any of these postcodes and is not listed in our list of towns\/villages, we are unable to help due to limitations on funding and volunteer numbers.<\/p><div class=\"quform-input quform-input-select quform-input-8_131 quform-cf\"><select id=\"quform_8_131_e7cb71\" name=\"quform_8_131\" class=\"quform-field quform-field-select quform-field-8_131\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"Bedwas\">Bedwas<\/option><option value=\"Trethomas\">Trethomas<\/option><option value=\"Graig-y-Rhacca\">Graig-y-Rhacca<\/option><option value=\"Machen\">Machen<\/option><option value=\"Lower Machen\">Lower Machen<\/option><option value=\"Draethen\">Draethen<\/option><option value=\"Waterloo\">Waterloo<\/option><option value=\"Rudry\">Rudry<\/option><option value=\"Michaelston-y-Fedw\">Michaelston-y-Fedw<\/option><option value=\"Cefn Mably\">Cefn Mably<\/option><option value=\"Caerphilly Town Centre\">Caerphilly Town Centre<\/option><option value=\"Lansbury Park\">Lansbury Park<\/option><option value=\"Mornington Meadows\">Mornington Meadows<\/option><option value=\"Castle Park\">Castle Park<\/option><option value=\"Wernddu\">Wernddu<\/option><option value=\"Trecenydd\">Trecenydd<\/option><option value=\"Energlyn\">Energlyn<\/option><option value=\"Penyrheol\">Penyrheol<\/option><option value=\"Llanbradach\">Llanbradach<\/option><option value=\"Senghenydd\">Senghenydd<\/option><option value=\"Abertridwr\">Abertridwr<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-select quform-element-8_132 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_132\"><label class=\"quform-label-text\" for=\"quform_8_132_e7cb71\">What is the primary reason the Service User needs assistance from us?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-8_132\"><p class=\"quform-description quform-description-above\">PLEASE NOTE: The option for \"Low Income\/Wages\" is for those who either are employed but their wages do not meet their general outgoings, or for parents who have an income but are not able to work due to childcare. Any other circumstance must be appropriately selected in this list.<\/p><div class=\"quform-input quform-input-select quform-input-8_132 quform-cf\"><select id=\"quform_8_132_e7cb71\" name=\"quform_8_132\" class=\"quform-field quform-field-select quform-field-8_132\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"Unemployed\">Unemployed<\/option><option value=\"Benefit Changes \/ Delays\">Benefit Changes \/ Delays<\/option><option value=\"Debt\">Debt<\/option><option value=\"Child Holiday Meals\">Child Holiday Meals<\/option><option value=\"Delayed Wages\">Delayed Wages<\/option><option value=\"Domestic Abuse\">Domestic Abuse<\/option><option value=\"Sickness \/ Ill Health\">Sickness \/ Ill Health<\/option><option value=\"No recourse of Public Funds\">No recourse of Public Funds<\/option><option value=\"Housebound\">Housebound<\/option><option value=\"Pensioner Poverty\">Pensioner Poverty<\/option><option value=\"Poor Mental Health\">Poor Mental Health<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-select quform-element-8_157 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_157\"><label class=\"quform-label-text\" for=\"quform_8_157_e7cb71\">Has the Service User been referred to us before?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-select quform-inner-8_157\"><div class=\"quform-input quform-input-select quform-input-8_157 quform-cf\"><select id=\"quform_8_157_e7cb71\" name=\"quform_8_157\" class=\"quform-field quform-field-select quform-field-8_157\"><option value=\"\" selected=\"selected\">Please select<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-8_158 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_158\"><label class=\"quform-label-text\" for=\"quform_8_158_e7cb71\">What was their previous referral number?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_158\"><div class=\"quform-input quform-input-text quform-input-8_158 quform-cf\"><input type=\"text\" id=\"quform_8_158_e7cb71\" name=\"quform_8_158\" class=\"quform-field quform-field-text quform-field-8_158\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-8_138 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_138\"><label class=\"quform-label-text\" for=\"quform_8_138_e7cb71\">Additional Details<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-8_138\"><p class=\"quform-description quform-description-above\">Please tell us how you reached a decision to refer this service user. <b>You must tell us in more detail as to why the service user needs support from us.<\/b> This is so that we can look to provide ongoing support for them, and to ensure our help is going to those most in need. <br><br>\n<b>We do <u>not<\/u> accept \"N\/A\" as an appropriate response, or simple sentences that reiterate that someone is in need. Referrals will not be accepted if this type of response is used in the field below.<\/b><\/p><div class=\"quform-input quform-input-textarea quform-input-8_138 quform-cf\"><textarea id=\"quform_8_138_e7cb71\" name=\"quform_8_138\" class=\"quform-field quform-field-textarea quform-field-8_138\"><\/textarea><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-8_124 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-group-title-description\"><h4 class=\"quform-group-title\">Service User Details<\/h4><p class=\"quform-group-description\">Please ensure that these details are filled in <b>accurately<\/b>. Thank you.<\/p><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-name quform-element-8_125 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_125\"><label class=\"quform-label-text\" id=\"quform_8_125_e7cb71_label\">Name<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-name quform-inner-8_125\"><div class=\"quform-input quform-input-name quform-input-8_125 quform-cf\"><div class=\"quform-element-row quform-2-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element-column\"><div class=\"quform-element quform-element-text quform-element-8_125_2 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-text quform-inner-8_125_2\"><div class=\"quform-input quform-input-text quform-input-8_125_2 quform-cf\"><input type=\"text\" id=\"quform_8_125_2_e7cb71\" name=\"quform_8_125[2]\" class=\"quform-field quform-field-text quform-field-8_125_2\" placeholder=\"First\" aria-labelledby=\"quform_8_125_e7cb71_label\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element-column\"><div class=\"quform-element quform-element-text quform-element-8_125_4 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-text quform-inner-8_125_4\"><div class=\"quform-input quform-input-text quform-input-8_125_4 quform-cf\"><input type=\"text\" id=\"quform_8_125_4_e7cb71\" name=\"quform_8_125[4]\" class=\"quform-field quform-field-text quform-field-8_125_4\" placeholder=\"Last\" aria-labelledby=\"quform_8_125_e7cb71_label\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-8_126 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_126\"><label class=\"quform-label-text\" for=\"quform_8_126_e7cb71\">Telephone Number<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_126\"><div class=\"quform-input quform-input-text quform-input-8_126 quform-cf\"><input type=\"text\" id=\"quform_8_126_e7cb71\" name=\"quform_8_126\" class=\"quform-field quform-field-text quform-field-8_126\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-8_127 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_127\"><label class=\"quform-label-text\" for=\"quform_8_127_e7cb71\">Address<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-8_127\"><div class=\"quform-input quform-input-textarea quform-input-8_127 quform-cf\"><textarea id=\"quform_8_127_e7cb71\" name=\"quform_8_127\" class=\"quform-field quform-field-textarea quform-field-8_127\"><\/textarea><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-8_128 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_128\"><label class=\"quform-label-text\" for=\"quform_8_128_e7cb71\">Postcode<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_128\"><div class=\"quform-input quform-input-text quform-input-8_128 quform-cf\"><input type=\"text\" id=\"quform_8_128_e7cb71\" name=\"quform_8_128\" class=\"quform-field quform-field-text quform-field-8_128\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-email quform-element-8_129 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_129\"><label class=\"quform-label-text\" for=\"quform_8_129_e7cb71\">Email address<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-email quform-inner-8_129\"><p class=\"quform-description quform-description-above\">If the Service User does not have an email address, please use your email address.<\/p><div class=\"quform-input quform-input-email quform-input-8_129 quform-cf\"><input type=\"email\" id=\"quform_8_129_e7cb71\" name=\"quform_8_129\" class=\"quform-field quform-field-email quform-field-8_129\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-email quform-element-8_130 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_130\"><label class=\"quform-label-text\" for=\"quform_8_130_e7cb71\">Confirm Email address<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-email quform-inner-8_130\"><div class=\"quform-input quform-input-email quform-input-8_130 quform-cf\"><input type=\"email\" id=\"quform_8_130_e7cb71\" name=\"quform_8_130\" class=\"quform-field quform-field-email quform-field-8_130\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-8_141 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_141\"><label class=\"quform-label-text\" for=\"quform_8_141_e7cb71\">Number of Adults in household?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_141\"><div class=\"quform-input quform-input-text quform-input-8_141 quform-cf\"><input type=\"text\" id=\"quform_8_141_e7cb71\" name=\"quform_8_141\" class=\"quform-field quform-field-text quform-field-8_141\" \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-text quform-element-8_142 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_142\"><label class=\"quform-label-text\" for=\"quform_8_142_e7cb71\">Number of Children in household?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-8_142\"><div class=\"quform-input quform-input-text quform-input-8_142 quform-cf\"><input type=\"text\" id=\"quform_8_142_e7cb71\" name=\"quform_8_142\" class=\"quform-field quform-field-text quform-field-8_142\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-date quform-element-8_147 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_147\"><label class=\"quform-label-text\" for=\"quform_8_147_e7cb71\">Referral Expiry Date<\/label><\/div><div class=\"quform-inner quform-inner-date quform-inner-8_147\"><p class=\"quform-description quform-description-above\">The Referral Expiry Date is shown below. Please make a note of this date for the Service User<\/p><div class=\"quform-input quform-input-date quform-input-8_147 quform-cf\"><input type=\"text\" id=\"quform_8_147_e7cb71\" name=\"quform_8_147\" class=\"quform-field quform-field-date quform-field-8_147\" placeholder=\"YYYY-MM-DD\" data-options=\"{&quot;format&quot;:&quot;&quot;,&quot;min&quot;:&quot;&quot;,&quot;max&quot;:&quot;&quot;,&quot;start&quot;:&quot;month&quot;,&quot;depth&quot;:&quot;month&quot;,&quot;showFooter&quot;:false,&quot;locale&quot;:&quot;en-GB&quot;,&quot;placeholder&quot;:&quot;&quot;,&quot;autoOpen&quot;:false,&quot;identifier&quot;:&quot;8_147&quot;}\" value=\"2026-07-21\" readonly \/><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-8_123 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-8_123\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Back<\/span><\/button><\/div><div class=\"quform-button-next quform-button-next-default quform-button-next-8_123\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-next\" value=\"submit\"><span class=\"quform-button-text quform-button-next-text\">Next<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-page quform-page-194 quform-page-8_194 quform-cf quform-group-style-plain quform-last-page\"><div class=\"quform-page-title-description\"><h3 class=\"quform-page-title\">Additional Questions<\/h3><p class=\"quform-page-description\">Please answer the following questions...<\/p><\/div><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-textarea quform-element-8_592901 quform-sr-only quform-cf\" style=\"clip: rect(1px, 1px, 1px, 1px); clip-path: inset(50%); position: absolute !important; height: 1px; width: 1px; overflow: hidden;\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_592901\"><label class=\"quform-label-text\" for=\"quform_8_592901_e7cb71\">Phone Number<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-8_592901\"><textarea id=\"quform_8_592901_e7cb71\" name=\"quform_8_592901\" class=\"quform-field quform-field-textarea quform-field-8_592901\" tabindex=\"-1\" autocomplete=\"new-password\"><\/textarea><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-8_204 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-checkbox quform-element-8_197 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_197\"><label class=\"quform-label-text\" id=\"quform_8_197_e7cb71_label\">Please tick all the statements that apply to you...<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-8_197\"><div class=\"quform-input quform-input-checkbox quform-input-8_197 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_8_197_e7cb71_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_8_197[]\" id=\"quform_8_197_e7cb71_1\" class=\"quform-field quform-field-checkbox quform-field-8_197 quform-field-8_197_1\" value=\"I have debts that I&#039;m struggling to pay \/ keep up with\" \/><label for=\"quform_8_197_e7cb71_1\" class=\"quform-option-label quform-option-label-8_197_1\"><span class=\"quform-option-text\">I have debts that I'm struggling to pay \/ keep up with<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_8_197[]\" id=\"quform_8_197_e7cb71_2\" class=\"quform-field quform-field-checkbox quform-field-8_197 quform-field-8_197_2\" value=\"I have been overdrawn on my bank account within the last 3 months\" \/><label for=\"quform_8_197_e7cb71_2\" class=\"quform-option-label quform-option-label-8_197_2\"><span class=\"quform-option-text\">I have been overdrawn on my bank account within the last 3 months<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_8_197[]\" id=\"quform_8_197_e7cb71_3\" class=\"quform-field quform-field-checkbox quform-field-8_197 quform-field-8_197_3\" value=\"My income does not cover my outgoings in a typical month\" \/><label for=\"quform_8_197_e7cb71_3\" class=\"quform-option-label quform-option-label-8_197_3\"><span class=\"quform-option-text\">My income does not cover my outgoings in a typical month<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_8_197[]\" id=\"quform_8_197_e7cb71_4\" class=\"quform-field quform-field-checkbox quform-field-8_197 quform-field-8_197_4\" value=\"I&#039;ve been bereaved in the last 12 months\" \/><label for=\"quform_8_197_e7cb71_4\" class=\"quform-option-label quform-option-label-8_197_4\"><span class=\"quform-option-text\">I've been bereaved in the last 12 months<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_8_197[]\" id=\"quform_8_197_e7cb71_5\" class=\"quform-field quform-field-checkbox quform-field-8_197 quform-field-8_197_5\" value=\"I feel that I have poor mental health\" \/><label for=\"quform_8_197_e7cb71_5\" class=\"quform-option-label quform-option-label-8_197_5\"><span class=\"quform-option-text\">I feel that I have poor mental health<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_8_197[]\" id=\"quform_8_197_e7cb71_6\" class=\"quform-field quform-field-checkbox quform-field-8_197 quform-field-8_197_6\" value=\"I am a parent and have a child aged 5 or under\" \/><label for=\"quform_8_197_e7cb71_6\" class=\"quform-option-label quform-option-label-8_197_6\"><span class=\"quform-option-text\">I am a parent and have a child aged 5 or under<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_8_197[]\" id=\"quform_8_197_e7cb71_7\" class=\"quform-field quform-field-checkbox quform-field-8_197 quform-field-8_197_7\" value=\"I am a single parent\" \/><label for=\"quform_8_197_e7cb71_7\" class=\"quform-option-label quform-option-label-8_197_7\"><span class=\"quform-option-text\">I am a single parent<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-8_198 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_198\"><label class=\"quform-label-text\" id=\"quform_8_198_e7cb71_label\">If we were able to offer free support to help you out of financial worry\/debt, would you be interested?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-8_198\"><div class=\"quform-input quform-input-radio quform-input-8_198 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_8_198_e7cb71_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_8_198\" id=\"quform_8_198_e7cb71_1\" class=\"quform-field quform-field-radio quform-field-8_198 quform-field-8_198_1\" value=\"Yes\" \/><label for=\"quform_8_198_e7cb71_1\" class=\"quform-option-label quform-option-label-8_198_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_8_198\" id=\"quform_8_198_e7cb71_2\" class=\"quform-field quform-field-radio quform-field-8_198 quform-field-8_198_2\" value=\"No\" \/><label for=\"quform_8_198_e7cb71_2\" class=\"quform-option-label quform-option-label-8_198_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-8_199 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_199\"><label class=\"quform-label-text\" for=\"quform_8_199_e7cb71\">Please explain why you do not want\/need help to solve your financial challenges?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-8_199\"><div class=\"quform-input quform-input-textarea quform-input-8_199 quform-cf\"><textarea id=\"quform_8_199_e7cb71\" name=\"quform_8_199\" class=\"quform-field quform-field-textarea quform-field-8_199\"><\/textarea><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-group quform-element-8_205 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-checkbox quform-element-8_206 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_206\"><label class=\"quform-label-text\" id=\"quform_8_206_e7cb71_label\">Has anything changed in your circumstances since you last requested a food parcel from us?<\/label><\/div><div class=\"quform-inner quform-inner-checkbox quform-inner-8_206\"><div class=\"quform-input quform-input-checkbox quform-input-8_206 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"group\" aria-labelledby=\"quform_8_206_e7cb71_label\"><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_8_206[]\" id=\"quform_8_206_e7cb71_1\" class=\"quform-field quform-field-checkbox quform-field-8_206 quform-field-8_206_1\" value=\"I&#039;ve gotten into debt\" \/><label for=\"quform_8_206_e7cb71_1\" class=\"quform-option-label quform-option-label-8_206_1\"><span class=\"quform-option-text\">I've gotten into debt<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_8_206[]\" id=\"quform_8_206_e7cb71_2\" class=\"quform-field quform-field-checkbox quform-field-8_206 quform-field-8_206_2\" value=\"I have been overdrawn on my bank account\" \/><label for=\"quform_8_206_e7cb71_2\" class=\"quform-option-label quform-option-label-8_206_2\"><span class=\"quform-option-text\">I have been overdrawn on my bank account<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_8_206[]\" id=\"quform_8_206_e7cb71_3\" class=\"quform-field quform-field-checkbox quform-field-8_206 quform-field-8_206_3\" value=\"I&#039;ve been bereaved\" \/><label for=\"quform_8_206_e7cb71_3\" class=\"quform-option-label quform-option-label-8_206_3\"><span class=\"quform-option-text\">I've been bereaved<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"checkbox\" name=\"quform_8_206[]\" id=\"quform_8_206_e7cb71_7\" class=\"quform-field quform-field-checkbox quform-field-8_206 quform-field-8_206_7\" value=\"I&#039;ve had a baby\" \/><label for=\"quform_8_206_e7cb71_7\" class=\"quform-option-label quform-option-label-8_206_7\"><span class=\"quform-option-text\">I've had a baby<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-8_207 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_207\"><label class=\"quform-label-text\" id=\"quform_8_207_e7cb71_label\">If we were able to offer free support to help you out of financial worry\/debt, would you be interested?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-8_207\"><div class=\"quform-input quform-input-radio quform-input-8_207 quform-cf\"><div class=\"quform-options quform-cf quform-options-block quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_8_207_e7cb71_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_8_207\" id=\"quform_8_207_e7cb71_1\" class=\"quform-field quform-field-radio quform-field-8_207 quform-field-8_207_1\" value=\"Yes\" \/><label for=\"quform_8_207_e7cb71_1\" class=\"quform-option-label quform-option-label-8_207_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_8_207\" id=\"quform_8_207_e7cb71_2\" class=\"quform-field quform-field-radio quform-field-8_207 quform-field-8_207_2\" value=\"No\" \/><label for=\"quform_8_207_e7cb71_2\" class=\"quform-option-label quform-option-label-8_207_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-8_208 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-8_208\"><label class=\"quform-label-text\" for=\"quform_8_208_e7cb71\">Please explain why you do not want\/need help to solve your financial challenges?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-textarea quform-inner-8_208\"><div class=\"quform-input quform-input-textarea quform-input-8_208 quform-cf\"><textarea id=\"quform_8_208_e7cb71\" name=\"quform_8_208\" class=\"quform-field quform-field-textarea quform-field-8_208\"><\/textarea><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-8_200 quform-cf\"><div class=\"quform-spacer\">Once the referral has been submitted the following will happen:\n<ul>\n \t<li>You will receive a confirmation email that your referral has been submitted.<\/li>\n \t<li>The Service User will have access to ongoing support from us until the expiry date of the referral number<\/li>\n \t<li>Within the next 10 minutes a <strong>referral number<\/strong> will be generated. This will be emailed directly to the Service User if you gave us their email address, or it will be emailed to you if you didn't provide an email address for the Service User. If you receive the referral number, you must pass this on to the Service User. Without it, they will not be able to get help from us.<\/li>\n<\/ul>\n<strong>IMPORTANT:<\/strong>\n\n<strong>The Service User must contact us each week to request help by using our website or our telephone support service. <\/strong>As soon as their referral number is received, they are able to start making their requests.\n\nBy submitting this request form, you are declaring that you have told the Service User how our system works, and that they agree to us holding their information in accordance with our Privacy Policy, and that we may use it to provide a service to them. You are also agreeing that we can hold the information you have submitted about yourself on our files.<\/div><\/div><div class=\"quform-element quform-element-html quform-element-8_202 quform-cf\"><div class=\"quform-spacer\"><strong>Did you know that The Parish Trust has a Baby Bank to help parents with baby equipment, clothes, and equipment? To find out more, <a href=\"https:\/\/theparishtrust.org.uk\/babybank\/\" target=\"_blank\" rel=\"noopener\">please click here<\/a> (link will open a new tab)<\/strong><\/div><\/div><div class=\"quform-element quform-element-html quform-element-8_203 quform-cf\"><div class=\"quform-spacer\"><b>You've told us that you've been Bereaved in the last 12 months. Did you know we offer bereavement\u00a0 support? <a href=\"https:\/\/theparishtrust.org.uk\/bereavement\/\" target=\"_blank\" rel=\"noopener\">Please click here for more information<\/a> (link opens in a new tab)<\/b><\/div><\/div><div class=\"quform-element quform-element-html quform-element-8_201 quform-cf\"><div class=\"quform-spacer\">By submitting this request form, you are agreeing that we may hold your information in accordance with our Privacy Policy, and that we may use it to provide a service to you.\n\nOnce your request is submitted, we will endeavour to action it as soon as reasonably possible. A volunteer will be in touch via telephone and\/or email to confirm your details. If you do not hear from us 48 hours (Monday-Friday), please telephone The Support Line on 02921 880 212, option 0.\n\nFollowing completion of your request, a volunteer may be in touch to follow up and check that everything went OK.<\/div><\/div><div class=\"quform-element quform-element-submit quform-element-8_195 quform-cf quform-button-style-theme\"><div class=\"quform-button-back quform-button-back-default quform-button-back-8_195\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-back\" value=\"back\"><span class=\"quform-button-text quform-button-back-text\">Back<\/span><\/button><\/div><div class=\"quform-button-submit quform-button-submit-default quform-button-submit-8_195\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-submit\" value=\"submit\"><span class=\"quform-button-text quform-button-submit-text\">Send<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/form><\/div><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-66fd6c27 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"66fd6c27\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;dce_visibility_selected&quot;:&quot;hide&quot;,&quot;enabled_visibility&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-4552cbf8\" data-id=\"4552cbf8\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":653,"featured_media":0,"parent":32708,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"give_campaign_id":0,"footnotes":""},"categories":[],"tags":[],"class_list":["post-32687","page","type-page","status-publish","hentry"],"campaignId":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/pages\/32687","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/users\/653"}],"replies":[{"embeddable":true,"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/comments?post=32687"}],"version-history":[{"count":0,"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/pages\/32687\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/pages\/32708"}],"wp:attachment":[{"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/media?parent=32687"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/categories?post=32687"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/theparishtrust.org.uk\/cy\/wp-json\/wp\/v2\/tags?post=32687"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}