Penlee Cluster Referral Form

Please complete this form for referral to The Penlee Cluster support service for parents and families covering West Penwith.

The information provided will help us to figure out what your support needs are and how our service can help you and your family.

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Name of first other Member of your Household
Multiple Choice

Name of second other Member of your Household
Multiple Choice (copy)

Name of third other Member of your Household
Multiple Choice (copy) (copy)

Do You Need Help with Understanding or Claiming Benefits?
Do You Need Help with council tax / housing benefit / UC?
Do You Need Help with Budgeting / Managing Money?

Do You Need Help with Getting information about accessing education / training / work?
Do You Need Support with Job Centre Appointments ?
Do You Need Help with Creating a CV?
Do You Need Help Looking into / applying for Child Care?

Do You Need Help with speaking to Other Agencies?

Do You Need Support with attending baby groups ?
Do You Need Support with accessing hobbies: Gym, fitness classes, groups?

Do You Have A Physical Health Condition / Disability?
Do You Have Suicidal Thoughts or Threats of Suicide?
Are You At Risk relating to Mental Health Issues?
Do You Display Self Neglect?
Do You Intentionally Harm Yourself?
Do you Misuse drugs / alcohol?
Are You A Risk to others due to drug / alcohol use?
Are You A Risk to others?
Are You A Victim of Harassment ?
Is there a Risk from Others (partner, family, friends)?
Do You Display Violence to Other Persons?
Did You Commit Criminal Offences?

The personal and sensitive personal information that is collected on this form will only be processed in connection with your application to support from us.
Your personal information will be kept securely on our systems.

At times it will be necessary to share your information with other organisation’s involved in your case, for example, social services, the police, health services and any other relevant organisations.
On these occasions the information will only be shared either with your agreement or if there is a legal reason to do so, and the information will be limited to the amount required for that purpose.
I authorise The Penlee Cluster to share any information which may be reasonably asked for in connection with my application for support from The Penlee Cluster.
All the answers and information I have given in this application are true to the best of my knowledge. I understand that if I give false information,
The Penlee Cluster may refuse or withdraw the service. If my circumstances change in any relevant way I will let you know.
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