This referral form provides details about a client seeking support from Men at Work, an organization providing support and advocacy for men experiencing family breakdown. The form collects information about the referring agency, the client's personal details, and notes on their current situation and support needs. Completed referrals should be emailed to Ben Rose, the project manager of Men at Work, or posted to their office at the Shipshape Health and Wellbeing Centre in Sheffield.

1. CLIENT REFERRAL FORM
Date:
Client Name:
REFERRING AGENCY’S DETAILS
Agency/organisation:
Referrer’s Name:
Relationship:
Telephone:
Mobile:
Email:
MEN AT WORK CLIENT DETAILS
Name:
Date of Birth: Age:
Address:
Postcode:
Telephone:
Mobile:
Email:
Please provide details of current situation and support needs
Note:
Electronic referrals to be returned by email to: BenRose.MenatWork@gmail.com
Printed copies to be returned by post to:
Men at Work, c/o Shipshape Health and Wellbeing Centre, The Stables, Sharrow Lane, Sheffield S11 8AE
Men at Work
Men’s Family Breakdown Support and Advocacy
ShipShape Health and Well-Being Centre
Chair: Andy Stockton - Secretary: Phil Eddyshaw - Treasurer: Chris Hanson
Tel: (0114) 250 0222 or 07960 835 980
Mr. Ben Rose
‘Men at Work’ Project Manager
C/o ShipShape Health &Well-Being Centre
The Stables, Sharrow Lane,
Sheffield S11 8AE
BenRose.MenatWork@gmail.com