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Solace CiviCRM Database
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Please enter the client's details below. An asterisk indicates the field is required
First Name
*
Last Name
*
Gender
*
- Select -
Female
Male
Transgender
Birth Date
*
Day
Day
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Month
Month
Jan
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May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Year
1920
1921
1922
1923
1924
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1926
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1930
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1932
1933
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1991
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2010
2011
2012
2013
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2015
2016
2017
2018
2019
2020
NHS Number
Click here to add spouse details (if any)
Spouse
First Name
Last Name
Gender
- None -
Female
Male
Transgender
Birth Date
Day
Day
1
2
3
4
5
6
7
8
9
10
11
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31
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Year
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
NHS Number
Click here to add children (if any)
Child 1:
First Name
Last Name
Date of Birth
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Year
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
Gender
- None -
Male
Female
Child 2:
First Name 2
Last Name 2
Date of Birth 2
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
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26
27
28
29
30
31
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Year
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
Gender 2
- None -
Male
Female
Child 3:
First Name 3
Last Name 3
Date of Birth 3
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Year
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
Gender 3
- None -
Male
Female
Child 4:
First Name 4
Last Name 4
Date of Birth 4
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Year
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
Gender 4
- None -
Male
Female
Child 5:
First Name 5
Last Name 5
Date of Birth 5
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Year
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
Gender 5
- None -
Male
Female
Client's Phone Number
*
Client Email Address
Client Address (If homeless, please use Referrer's Address)
*
Address Line 2
City
*
Postcode
*
Country of Origin
*
- Select -
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Bulgaria
Azerbaijan
Bahamas, The
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Cape Verde
Comoros
Bosnia
Botswana
Brazil
Britain
Brunei
Burkina Faso
Burma
Burundi
Cambodia
Cameroon
Canada
Cape Verdi Isla
Central African Republic
Chad
Chile
China
Colombia
Congo
Cuba
Egypt
Equador
Eritrea
Ethiopia
Finland
France
Gambia
Georgia
Ghana
Greece
Guinea
Haiti
Holland
India
Indonesia
Iran
Iraq
Ivory Coast
Jamaica
Kenya
Kosovo
Lebenan
Kurdistan
Kuwait
Latvia
Lebanon
Liberia
Libya
Lithuania
Malawi
Mali
Mauritania
Mongolia
Morocco
Ndelebe
Nigeria
North Korea
Pakistan
Palestine
Poland
Rohingyia
Romania
Russia
Rwanda
Saudi Arabia
Senegal
Serbia
Sierra Leone
Somalia
South Africa
Spain
Sri Lanka
St Lucian
Sudan
Syria
Taiwan
Tanzania
Togo
Trinida
Turkey
Uganda
UK
USA
Venezuela
Verde
Vietnam
Yemen
Zambia
Zimbabwe
Gabon
Tunisia
Namibia
Date of arrival in UK
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Year
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
2051
2052
2053
2054
2055
2056
2057
2058
2059
2060
2061
2062
2063
2064
2065
2066
2067
2068
2069
2070
Home Office Status
- None -
Asylum Seeker
ELR
ILR
Humanitarian Protection
Discretionary Leave to remain
Refugee
Refused Asylum Seeker
Detained
Removed
Marriage Visa
Unaccompanied Minor (UASC)
Home Office/VPR Number
Privacy Preferences
Do not email
Do not phone
Do not mail
Do not sms
Do not trade
NO BULK EMAILS (User Opt Out)
Religion
- None -
Christian
Jewish
Muslim
Buddhist
Hindu
Sikh
Atheist
Other
Not Specified
Ethnic Identity
- None -
Asian or Asian British - Bangladeshi
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Black or Black British - African
Black or Black British - Caribbean
Chinese
Mixed - White and Asian
Mixed - White and Black African
Mixed - White and Black Caribbean
Mixed - Any Other Mixed Background
White - British
White - Irish
White - Any Other White Background
Any Other
Not Known/Not provided
other Asian (Middle east)
Arabic
Relationship Status
- None -
Married
Single
Co-habiting
Civil Partnership
Other
Did not want to answer
Not asked
Child
Languages Spoken (Use the Control button to make multiple selections)
English
Albanian
Amharic
Arabic
Assyrian
Azeri
Bandjoun
Bashewi
Beluchi
Bemba
Bena
Bengali
Bilen
Bosnian
British Sign Language
Burmese
Cantonese
Chaldean
Chichewa
Creole
Dari
Dutch
Edo
Esperanto
Farsi
Finnish
Flemish
French
Fulah
Georgian
German
Greek
Hausa
Hebrew
Hindi
Hindko
Igbo
Ijaw (Kalaburi)
Indonesian
Iroba
Italian
Japanese
Kannada
Kikonga
Kinya Rwanda
Kirundi
Kituba
Korean
Kurdish Bhadini
Kosovan
Krio (Sierra Leone)
Kurdish Sorani
Kurmanji
Lingala
Lithuanian
Luganda Run-joakole
Lukiga Rutooro
Lun-jarwanda
Lunoro/Lun-joro
Latvian
Malay
Maltes
Mandarin
Mandingo
Mandinka
Mirpuri
Ndebele
Nepali
Norwegian
Nyanji
Pahari
Pashtu
Polish
Portuguese
Punjabi
Rohingyian
Roma
Romanian
Runyankolet
Russian
Serbo-Croat
Slavic/Slavonic
Shona
Somali
Sri Lankan
Spanish
Susu
Swahili
Swati
Swedish
Tamil
Thai
Tigre
Tigrinya
Tshiluba
Turkish
Twi
Ugandan
Ukrainian
Urdu/Hindi
Urdu
Vietnamese
Wolof
Xhosa
Youruba (Nigeria)
Zulu
Needs an Interpreter?
*
Yes
No
Date Referred
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Year
2018
2019
2020
2021
2022
Referred through Syrian Resettlement Programme?
Yes
No
Identifies as Disabled
Yes
No
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Math question
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