Name of Referrer (your name) *

First Name

Last Name

NIHE Tenant Name *

First Name

Last Name

Known by any other names?

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Support requested *

You can select more than one type of support listed below

Counselling (one to one talking therapy)

Money Management (budgeting) support

Open Door drop in (befriending/support)

RESET Social Supermarket

Remote Tenant Support call

Emergency Support for White Goods

White goods requested *

You can select more than one type of appliance listed below

Not required

Cooker

Washing Machine

Full size Fridge/Freezer

Under counter Fridge

Under counter Freezer

CONSENT CONFIRMATION *

Please read this statement below to request consent from the person: "To provide you with the best possible support, Vineyard Compassion need your consent to gather, process and store your personal information (potentially including sensitive information such as health and finances) and if required, to share information with relevant organisations. For example: • Where it is important for the support that you have agreed to receive, including very limited information for funding purposes. • There is a concern for your welfare or that of others. • We have a legal obligation to do so. You have the legal right to request access to the information that Vineyard Compassion hold about you or to withdraw your consent at any time. Further information is available on the VC website or by calling the Hope Centre office. Do you confirm that you understand this statement and give your consent." Please check this box if you have received full consent from this person above to share their personal information with Vineyard Compassion.

Consent given