Your details
Your title Mr Miss Mrs Ms Mx Dr Lady Rev Councillor Br Sr Professor Rabbi Father Sir Brigadier Master Other
Your first name
Your last name
Phone number, if a landline please include the area code
Email address, if completed you will receive a PDF copy of your form
Are you a Salford resident? Yes No
Select Address No properties found or searched for
Your selected address
Please provide your address
Please provide your address
How are you submitting this form? Self – using own/family/friend device Member of SA/HSF staff completing on your behalf Using computer at Gateway or Broughton Hub without assistance Using computer at Gateway or Broughton Hub with assistance from member of staff Referral agency completing on clients behalf Other (please specify)
Please specify further details:
Please select which agency Adult Social Care CAB Coming home project Council Tax Early Help / Childrens Services Family Hubs For Housing GPs HIT Hospital Discharge team Housing Options Housing benefits Mustard Tree Palliative care Pendleton Together Public Health Salford Foundation Salix Homes Supported Tenancies WRDA Other (please provide further info)
Please provide Referral agency details, including name, address and contact details
Where did you hear about this support? Gateway centre LIFE in Salford magazine Member of council staff Outdoor advertising board Printed materials (e.g. poster or leaflet) Salford City Council social media Website (e.g. Google search) Word of mouth (e.g. friend or family member) Other (please provide further information)
Please provide further information on where you heard about this support
Landlord Details City West For Housing Homeowner Pendleton Together Private rented Salix Homes Other
What is your ethnic origin or background? Any other ethnic group Arabic Asian or Asian British Asian or Asian British-any other asian background Asian or Asian Birtish-Bangladeshi Asian or Asian British-East african asian Asian or Asian British-Indian Asian or Asian British-Kashmiri Asian or Asian British-mixed asian Asian or Asian British-Pakistani Asian or Asian British-Punjabi Asian or Asian British-Sinhalese Asian or Asian British-Sri Lanka Asian or Asian British-Tamil Black British Black/Black British African Black or Black British-any other black background Black or Black British-Caribbean Black or Black British-mixed black Black or Black British-Nigerian Black or Black British-Somali Prefer not to say White – British/ English/ Welsh/ Scottish/ North Irish/ White Irish Chinese Filipino Gypsy or Roma Japanese Jewish Malaysian Mixed asian and chinese Mixed black and asian Mixed black and chinese Mixed black and white Mixed-white and asian Mixed white and chinese Mixed-other mixed background Mixed-white and black african Mixed-White and black caribbean Other white background Refused Traveller of irish heritage unknown Vietnamese White Albanian White All Republic former USSR White Bosnian White British White Cornish White Croatian White Cypriot White English White Greek White Greek Cypriot White Irish White Italian White Kosovan White mixed White Northern Irish White other republic former Yugoslavia White Polish White Scottish White Serbian White Turkish White Turkish Cypriot White Welsh
Do you regard yourself as belonging to any of the following? Buddhist Christian Hindu Jewish Muslim Sikh Other Prefer Not to say
Sorry, you can only apply if you are a Salford resident.
