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Food Bank (self referral) form
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* Indicates required question
Forename
*
Your answer
Surname
*
Your answer
Gender
*
Female
Male
Other:
Date of birth
*
MM
/
DD
/
YYYY
Full Address
*
Your answer
Post Code
*
Your answer
Mobile Number
*
Your answer
# Adults living in your household
*
Choose
1 (self)
2
3
4
5
6
7
8
9
10+
# Children living in your household?
*
Choose
1
2
3
4
5
6+
None
What is your current living situation?
*
Choose
Council Housing
Shared House
Hostel
Private Rental
Living with extended family
Homeless
Do you feel safe in your current housing?
*
Yes
No
Other:
Ethnicity
Arab
Asian
Black African
Black Caribbean
Latino/Hispanic
White
Mixed
Other:
Faith
Choose
Buddhist
Christian
Hindu
Jewish
Muslim
Atheist
Agnostic
Other
Allergies/Dietary requirements
*
Your answer
Reason for support
*
Choose
Benefits Recently Stopped
Domestic Abuse
Disability
Homeless
Low Income
Mental Health
Redundancy
Are you receiving any other forms of support? (Check all that apply)
*
Universal Credit
Child Credit
Jobseeker's Allowance (JSA)
Pension Credit
Income Support
None
Other:
Required
How often do you struggle to get enough food?
*
Daily
Weekly
Monthly
Once in a while
What is your current employment status?
*
Full-time employed
Part-time employed
Self-employed
Unemployed
Do you struggle with your Mental Health?
*
Yes
No
Are you open to receiving additional support from the Council?
*
Yes
No
How did you hear about us
Your answer
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