Referring for Support at The ClementJames Centre

Thank you for taking the time to fill out this referral form. If you need support filling out this form, please contact reception@clementjames.org or give us a call on 020 7221 8810.

Privacy Notice

At The ClementJames Centre, we're committed to protecting and respecting your privacy.

Please see our privacy notice attached here, and tick here when you have read and agree to the terms laid out in it.

Who We Can Support

Please be aware that we can only support residents who live in or who are housed in either Kensington & Chelsea, Hammersmith & Fulham or Westminster.

Please select the borough the client is a resident of or housed in:

We also have criteria that clients need to meet to access support. At least one of the following means that they are able to access support at the Centre.

Please select any of the following that apply to the client:

Receiving benefits

Have a household income of less than £25,000

Living in social housing (this includes council, temporary accommodation and housing associations)

Have a child/ward receiving free school meals

Your Details

It is helpful for us to have your details, should we need to contact you about this referral.

Full Name

Organisation

Other:

Role

Contact Number

How will you still be working with the client being referred to us going forward?

Can we contact you about this referral? We will only do so to discuss details relating to the referral, when such details are needed in order to best support the client.

Please tick here if you would like to be subscribed to our mailing list to hear about future workshops, programmes, events and opportunities at The ClementJames Centre.

Support Referral

What is the main type of support that you are enquiring about for the client?

The funders of our Wellbeing Support programme ask that we collect information about GP practices. If the client feels uncomfortable and would like to discuss this information further, please contact reception@clementjames.org or give us a call on 020 7221 8810.

What is the name of the client's GP practice?

Other:

Which of the following programmes do you perceive to be best suited to the circumstances of the client?

Booster Programme: Short-term unemployed (3-6 months)Refresh Programme: Medium term unemployed (6-12 months)Spark Programme: Long-term unemployed (12 + months)

Enhance Programme: Employed, but financially unstable & in receipt of means-tested benefits

Please tell us, in as much detail as possible, what the client would like support with:

Please select the other types of support that the client is interested in receiving at ClementJames:

Wellbeing Support - We support people to be able to look after their own wellbeing and

that of their family and friends

Please select the other types of support that the client is interested in receiving at ClementJames:

Employment Skills Programme - We equip people with the skills to feel more job ready and to achieve their employment goals

Client's Details

First Name

Last Name

Date of Birth (dd/mm/yy)

Gender

Client's self-described gender, if known:

Ethnicity

Other or client's self-described ethnicity, if know:

Contact Number

House Number & Street Name

Post Code

Client's Language and Communication Needs

We ask the following questions in order to provide the best support for the client throughout their time at The ClementJames Centre. Please provide as much information as you can.

Does the client have any learning or physical accessibility needs that we should know about?

Please provide us with more details:

Does the client have any communication or language needs that we should know about?

Please provide us with more details:

We offer English classes for adults. Would the client like to find out more about how we can support them with this?

Please tick here if the client needs assistance to exit the building in the event of an emergency evacuation. Staff will prepare a Personal Emergency Evacuation Plan (PEEP) for them.

Submit Your Form

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