Register for Support Have you registered with The ClementJames Centre already? Yes, I have completed an online registration form. Great! Click here to book an assessment.No, I need to complete an online registration form. Please click "Next Page" below to complete the form. Getting 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 If you do not fit our criteria but would like our help to find an organisation who can support you, please contact reception@clementjames.org or give us a call on 020 7221 8810. Please be aware that we can only support residents who live in or who are housed in Kensington & Chelsea for Advice Support, and Kensington & Chelsea, Hammersmith & Fulham or Westminster for Wellbeing and Employment Support. Please select the borough you are a resident of housed in:Please select... Kensington & Chelsea Hammersmith & Fulham Westminster We also have criteria that clients need to meet to access support. At least one of the following means that you are able to access support at the Centre.Please select any of the following that apply to you: Receiving benefits Have a household income of less than £25,000 Living in social housing (this includes council, temporary accommodation and housing associations) Child/ward receiving free school meals Your Details TitlePlease select... Mr. Ms. Mrs. Dr. Prof. Mx. Miss First Name Last Name Date of Birth (dd/mm/yyyy) GenderPlease select... Male Female Non-binary Prefer to self-describe Prefer not to say Self-described gender: EthnicityPlease select... Indian Pakistani Bangladeshi Chinese Any other Asian background Caribbean African Moroccan Eritrean Ethiopian Any other Black, Black British, or Caribbean background White and Black Caribbean White and Black African White and Asian Any other Mixed or multiple ethnic background English, Welsh, Scottish, Northern Irish or British Irish Gypsy or Irish Traveller Roma Any other White background Arab Any other ethnic group Prefer to self-describe Prefer not to say Other or self-described ethnicity: Email Contact Number House Number & Street Name Post Code How did you hear about The ClementJames Centre?Please select... Migrants Organise Breaking Barriers Cardinal Hume Centre Shelter RBKC Other local authority Outreach (job fair, event) Community Living Well Crosslight Citizens Advice Grenfell Dedicated Service Look Ahead JobCentrePlus NHS Self-referral Housing Association Friend/Family Support Worker Online Other Please tick here if you would like to be subscribed to our mailing list to hear about upcoming workshops, programmes, events and opportunities at The ClementJames Centre. There are times when photographs of activities are taken for publicity and marketing purposes. This is really helpful for us to be able to show what we are doing in the community. Please tick here if you agree for your image to be used in this way. Your Emergency Contact's Details In the event of an emergency, it is really helpful for us to have someone we can contact for you. This could be a partner, relative or friend, for example. Emergency Contact Full Name Emergency Contact Number Your Language and Communication Needs We ask the following questions in order to provide the best support for you throughout your time at The ClementJames Centre. Do you have any learning or physical accessibility needs that we should know about?Please select... Yes No Please provide us with more details: Do you have any communication or language needs that we should know about?Please select... Yes No Please provide us with more details: We offer English classes for Adults. Would you like to find out more about how we can support with this?Please select... Yes No Please tick here if you need assistance to exit the building in the event of an emergency evacuation. Staff will prepare a Personal Emergency Evacuation Plan (PEEP) for you. Submit Your Form Please submit the form below. Once you have pressed submit you will be taken to a booking page to book your Welcome Meeting. Contact Information