Community Solutions Lancashire Referral Form

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Food Bank Opening Hours Monday to Friday 10.00am – 4.00pm

Food Parcel Referral Form

Client Details Please complete all fields and provide as much appropriate information as possible
Full Name
Address
Town / Single Bag / Cat or Dog Food
Post Code / Family Bag / Toiletries
one bag per referral
Date of Birth / Large Family Bag / Brunch Parcel
Contact Number(s)
Clients will be contacted prior to any delivery attempt. They must be present at the address provided or risk missing their parcel. If a telephone contact is not available please arrange a referral collection.
Additional Household Members
Names and ages of adults and children. / 1
2
3
4
5
6 / Number of weeks required? Maximum 4 weeks
Does the person have cooking facilities?
Please outline any special dietary needs
Are there any risk factors?
Preferred Delivery / Tuesday 1:00pm - 3:00pm / Thursday 1:00pm - 3:00pm
Our volunteers deliver during the time slots indicated above. We are unable to deliver to clients recently released from prison or those who may put our volunteers at risk. Referring agency collection is available on request. Please indicate your request below. We do not offer client collection from our office location.
Collection / Monday / Tuesday / Wednesday / Thursday / Friday
What is the reason for the referral? Please provide as much detail as possible so that we can accurately assess the referral.
Referring Agency Details
Referrers Name / Agency
Contact Number / Email
I confirm that the client has given verbal consent for their details to be shared with partner agencies. Please Tick

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