REFERRAL TO GEORGE HOUSE TRUST

REFERRAL TO GEORGE HOUSE TRUST

If you are a healthcare professional making a referral with your patient's consent, please complete the form.  The referral process is encrypted and secure.   We will contact the patient within three working days of receiving the request.

 

Please note that due to the current circumstances regarding coronavirus, we are supporting people living with HIV by telephone only.  Please continue to refer in the usual way and we will endeavour to still contact the patient within the three working days.

 

Your organisation
Service User
Please provide the following details for your service user to refer them to GHT
Was the diagnosis made within the last 12 months?

George House Trust Welfare Fund

ABOUT YOU

IMPORTANT NOTE: Unfortunately, we will not be able to grant a cooker, washing machine, fridge/freezer or bed frames as you are currently living with friends/relatives, in temporary accommodation or hostel or are homeless.  Please make an application for any one of these items when you are in permananet accommodation with a private or housing association tenancy agreement and where this item is not included on the inventory or supplied as part of a furnished or part-furnished let.

 

You can continue with your application for other items.

SOURCES OF INCOME
Please tick all that apply. You will not be asked to disclose how much salary or benefit(s) you receive.
BENEFIT COMPONENT
Enter the name of the other benefit(s) you receive
WHAT YOU ARE APPLYING FOR

Unfortunately, we will not be able to grant a cooker, washing machine, fridge/freezer or bed frames as you are currently living with friends/relatives, in temporary accommodation or hostel or are homeless.  Please make an application for any one of these items when you are in permananet accommodation with a private or housing association tenancy agreement and where this item is not included on the inventory or supplied as part of a furnished or part-furnished let.

 

You can continue with an application for other items by makng another selection for any item not marked with *

 

 

Welfare Fund: GAS COOKER
 
You are making an application for a GAS COOKER.  You must read the following statements carefully.  You will be asked to tick a box to indicate that you agree to these terms.  If you are unable to agree to these terms, we will unfortunately not be able to proceed with your application for this item.
 
I acknowledge that, if my application is successful, the item requested above will be delivered to my home.  The goods have been funded by the George House Trust Welfare Fund and the item will be supplied by the supplier chosen by George House Trust.
 
I understand and agree to the following:
  1. The gas cooker will be fitted by a qualified installer, arranged through the supplier, and I am not permitted to arrange independent installation as an alternative.  George House Trust will not supply gas cookers which are not delivered brand new and which are not fitted by the supplier.
  2. The welfare fund will cover the cost of standard installation and there must be a suitable gas supply in the vicinity of where the cooker is to be sited for the installation to take place.
  3. I understand that I will be responsible for any additional charges that may be necessary if a gas supply or fittings needs to be installed or replaced.
  4. My old appliance will be taken away by the installer.
  5. If the item is faulty, or becomes faulty at a later date, I am responsible for contacting the supplier from where the item was bought.
  6. The item will be delivered to my home address. This address is the one recorded on the George House Trust database.
  7. If the arrangements made for delivery at the time of ordering are not convenient for me I am responsible for making any necessary alternative arrangements myself by contacting the supplier on the phone number below.
  8. I am responsible for ensuring that I (or my representative) is at my home address to receive the item when it is delivered.
  9. The make and model of the item will be decided by George House Trust on the basis of the information I have supplied and I will not be able to change or amend the order.
Welfare Fund: ELECTRIC COOKER
 
You are making an application for an ELECTRIC COOKER.  You must read the following statements carefully.  You will be asked to tick a box to indicate that you agree to these terms.  If you are unable to agree to these terms, we will unfortunately not be able to proceed with your application for this item.
 
I acknowledge that, if my application is successful, the item requested above will be delivered to my home.  The goods have been funded by the George House Trust Welfare Fund and the item will be supplied by the supplier chosen by George House Trust.
 
I understand and agree to the following:
  1. The electric cooker will be fitted by a qualified installer, arranged through the supplier, and I am not permitted to arrange independent installation as an alternative.  George House Trust will not supply electric cookers which are not delivered brand new and which are not fitted by the supplier.
  2. The welfare fund will cover the cost of standard installation and there must be suitable electrical sockets in the vicinity of where the cooker is to be sited for the installation to take place.
  3. I understand that I will be responsible for any additional charges that may be necessary if wiring needs to be installed or replaced.
  4. My old appliance will be taken away by the installer.
  5. If the item is faulty, or becomes faulty at a later date, I am responsible for contacting the supplier from where the item was bought.
  6. The item will be delivered to my home address. This address is the one recorded on the George House Trust database.
  7. If the arrangements made for delivery at the time of ordering are not convenient for me I am responsible for making any necessary alternative arrangements myself by contacting the supplier on the phone number below.
  8. I am responsible for ensuring that I (or my representative) is at my home address to receive the item when it is delivered.
  9. The make and model of the item will be decided by George House Trust on the basis of the information I have supplied and I will not be able to change or amend the order.
Welfare Fund: FRIDGE/FREEZER
 
You are making an application for a FRIDGE, FREEZER or a FRIDGE/FREEZER.  You must read the following statements carefully.  You will be asked to tick a box to indicate that you agree to these terms.  If you are unable to agree to these terms, we will unfortunately not be able to proceed with your application for this item.
 
I acknowledge that, if my application is successful, the item requested above will be delivered to my home.  The goods have been funded by the George House Trust Welfare Fund and the item will be supplied by the supplier chosen by George House Trust.
 
I understand and agree to the following:
  1. The welfare fund does not cover the cost of installation of a fridge, freezer or a fridge/freezer and I understand that I will be responsible for any additional charges if I seek professional installation of the appliance.
  2. My old appliance will be taken away by the supplier.
  3. If the item is faulty, or becomes faulty at a later date, I am responsible for contacting the supplier from where the item was bought.
  4. The item will be delivered to my home address. This address is the one recorded on the George House Trust database.
  5. If the arrangements made for delivery at the time of ordering are not convenient for me I am responsible for making any necessary alternative arrangements myself by contacting the supplier on the phone number below.
  6. I am responsible for ensuring that I (or my representative) is at my home address to receive the item when it is delivered.
  7. The make and model of the item will be decided by George House Trust on the basis of the information I have supplied and I will not be able to change or amend the order.
Welfare Fund: TUMBLE DRYER
 
You are making an application for a TUMBLE DRYER.  You must read the following statements carefully.  You will be asked to tick a box to indicate that you agree to these terms.  If you are unable to agree to these terms, we will unfortunately not be able to proceed with your application for this item.
 
I acknowledge that, if my application is successful, the item requested above will be delivered to my home.  The goods have been funded by the George House Trust Welfare Fund and the item will be supplied by the supplier chosen by George House Trust.
 
I understand and agree to the following:
  1. The welfare fund does not cover the cost of installation and I understand that I will be responsible for any additional charges if I seek professional installation of the appliance.
  2. My old appliance will be taken away by the supplier.
  3. If the item is faulty, or becomes faulty at a later date, I am responsible for contacting the supplier from where the item was bought.
  4. The item will be delivered to my home address. This address is the one recorded on the George House Trust database.
  5. If the arrangements made for delivery at the time of ordering are not convenient for me I am responsible for making any necessary alternative arrangements myself by contacting the supplier on the phone number below.
  6. I am responsible for ensuring that I (or my representative) is at my home address to receive the item when it is delivered.
  7. The make and model of the item will be decided by George House Trust on the basis of the information I have supplied and I will not be able to change or amend the order.
Welfare Fund: MICROWAVE OVEN
 
You are making an application for a MICROWAVE OVEN.  You must read the following statements carefully.  You will be asked to tick a box to indicate that you agree to these terms.  If you are unable to agree to these terms, we will unfortunately not be able to proceed with your application for this item.
 
I acknowledge that, if my application is successful, the item requested above will be delivered to my home.  The goods have been funded by the George House Trust Welfare Fund and the item will be supplied by the supplier chosen by George House Trust.
 
I understand and agree to the following:
  1. If the item is faulty, or becomes faulty at a later date, I am responsible for contacting the supplier from where the item was bought.
  2. The item will be delivered to my home address. This address is the one recorded on the George House Trust database.
  3. If the arrangements made for delivery at the time of ordering are not convenient for me I am responsible for making any necessary alternative arrangements myself by contacting the supplier on the phone number below.
  4. I am responsible for ensuring that I (or my representative) is at my home address to receive the item when it is delivered.
  5. The make and model of the item will be decided by George House Trust on the basis of the information I have supplied and I will not be able to change or amend the order.
Welfare Fund: BED FRAME / MATTRESS
 
You are making an application for a BED FRAME and/or MATTRESS.  You must read the following statements carefully.  You will be asked to tick a box to indicate that you agree to these terms.  If you are unable to agree to these terms, we will unfortunately not be able to proceed with your application for this item.
 
I acknowledge that, if my application is successful, the item requested above will be delivered to my home.  The goods have been funded by the George House Trust Welfare Fund and the item will be supplied by the supplier chosen by George House Trust.
 
I understand and agree to the following:
  1. If the item is faulty, or becomes faulty at a later date, I am responsible for contacting the supplier from where the item was bought.
  2. The item will be delivered to my home address. This address is the one recorded on the George House Trust database.
  3. If the arrangements made for delivery at the time of ordering are not convenient for me I am responsible for making any necessary alternative arrangements myself by contacting the supplier on the phone number below.
  4. I am responsible for ensuring that I (or my representative) is at my home address to receive the item when it is delivered.
  5. The make and specification of the item will be decided by George House Trust on the basis of the information I have supplied and I will not be able to change or amend the order.
Welfare Fund: VACUUM CLEANER
 
You are making an application for a VACUUM CLEANER.  You must read the following statements carefully.  You will be asked to tick a box to indicate that you agree to these terms.  If you are unable to agree to these terms, we will unfortunately not be able to proceed with your application for this item.
 
I acknowledge that, if my application is successful, the item requested above will be delivered to my home.  The goods have been funded by the George House Trust Welfare Fund and the item will be supplied by the supplier chosen by George House Trust.
 
I understand and agree to the following:
  1. If the item is faulty, or becomes faulty at a later date, I am responsible for contacting the supplier from where the item was bought.
  2. The item will be delivered to my home address. This address is the one recorded on the George House Trust database.
  3. If the arrangements made for delivery at the time of ordering are not convenient for me I am responsible for making any necessary alternative arrangements myself by contacting the supplier on the phone number below.
  4. I am responsible for ensuring that I (or my representative) is at my home address to receive the item when it is delivered.
  5. The make and model of the item will be decided by George House Trust on the basis of the information I have supplied and I will not be able to change or amend the order.
Welfare Fund: WASHING MACHINE
 
You are making an application for a WASHING MACHINE.  You must read the following statements carefully.  You will be asked to tick a box to indicate that you agree to these terms.  If you are unable to agree to these terms, we will unfortunately not be able to proceed with your application for this item.
 
I acknowledge that, if my application is successful, the item requested above will be delivered to my home.  The goods have been funded by the George House Trust Welfare Fund and the item will be supplied by the supplier chosen by George House Trust.
 
I understand and agree to the following:
  1. The washing machine will be fitted by a qualified installer, arranged through the supplier, and I am not permitted to arrange independent installation as an alternative.  George House Trust will not supply washing machines which are not delivered brand new and which are not fitted by the supplier.
  2. The Welfare Fund covers the cost of a standard installation.  Adequate water inlet and waste pipes and an electrical socket must be available in the vicinity of where the washing machine is to be located for the installation to take place.  
  3. My old appliance will be taken away by the supplier.
  4. If the item is faulty, or becomes faulty at a later date, I am responsible for contacting the supplier from where the item was bought.
  5. The item will be delivered to my home address. This address is the one recorded on the George House Trust database.
  6. If the arrangements made for delivery at the time of ordering are not convenient for me I am responsible for making any necessary alternative arrangements myself by contacting the supplier on the phone number below.
  7. I am responsible for ensuring that I (or my representative) is at my home address to receive the item when it is delivered.
  8. The make and model of the item will be decided by George House Trust on the basis of the information I have supplied and I will not be able to change or amend the order.
We will not be able to consider your application for the able item without your agreement to the above terms

Grants for clothing are made by store vouchers for £150.  Until further notice, you will not be able to collect from our office and vouchers will be posted to you.  We may be able to arrange e-vouchers, which can be emailed to you, subject to store avaialbility.

Bed sets will be delivered to your home.  Bed sets are 1 x quilt, 2 x pillows and  plain-dyed sets consisting of 2 x duvet covers, 4 x pillow cases and 2 x sheets.  Quilts will have polyester fibre filling and the TOG rating may vary.  We do not make cash payments for bed sets.

Grants for 6 months membership will be made by voucher, redeemable at your local Pure Gym.  We do not make cash payments for gym membership.   

EXPENSES

IMPORTANT NOTE: Please provide as much information as possible in your responses to the following questions.  Your application is more likely to be accepted if you provide full supporting information as the Panel can more easily make a decision based on your circumstances and the reasons for your application.

 

 

If you have any unusual or high expenses, including debt repayments that impact heavily on your budget, tell us about them here.  Examples include debt repayments and care and mobility costs in relation to disabilities.  We may be able to provide additional services to help your debts be managed, including negotiating payment plans on your behalf or sourcing other means to reduce your outgoings.

George House Trust can provide specialist advice and advocacy if you are experiencing problems managing debt.  Would you like someone to call you to discuss the support we can offer? 
 

Our Adviser will call you back.
 
If your personal and/or financial situation has been affected by Covid 19 please explain how. Examples include the following:
 
  • You or a member of your household have or have had Covid-19
  • You have received a government letter advising you to shield
  • You have lost your job, been furloughed or have lost work
     
 
If you do not have any unusual or high expenses or have not been significantly impacted by Covid-19, use this space to describe your circumstances as fully as you can to support your application.

Living with HIV? Want to talk to us?
Call 0161 274 4499 or email: talk@ght.org.uk

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