Referral form Employment Support
Referral form for
Contact details of refer
Name
Job Title
Phone No
Support Request
Work Preperation
Supported employment
Date Submitted
Please help us to process this referral as quickly as possible by completed the form as fully as possible. If we require further information to enable us to process this referral we may need to return it which may delay the case being allocated.
None of the information will be shared with employers unless it is considered appropriate, however completing the information as fully as possible will assist us in focusing on the appropriate support required to support an individual into employment. It will also ensure that assessments are undertaken safely and appropriately and that we are able to seek the most appropriate work opportunities.
Please return completed form either by post to
Vicky Jessop – Commissioning Officer
3rd Floor West EII Court
The Castle
Winchester
SO23 8UQ
Or by email to -
Personal information
SWIFT No.
Name
Date of Birth
Preferred form of address
Address
Post Code
Telephone No.
Mobile Phone No.
National Insurance No
Method of initial Contact
Telephone Email Letter Text message
Direct with applicant Support worker
Parent Care Manager
Please let us know if there is any other information about communication that you think would be useful for our initial contact.
Educational attainment
This could include are work preparation, travel training, or life skills courses.
Course title / Date achieved / School / organisationWork Experience
Employer / Tasks undertaken / Hours worked / Dates / Paid / unpaidFinding work
Please let us know what interests and hobbies this person has which might be relevant to finding employment.
What other support is needed to assist this person into employment?
How many hours do they want to work?
Are there any days that they are unable to work?
Please note that most retail outlets are now requiring some weekend availability for paid employment.
Monday Tuesday Wednesday Thursday
Friday Saturday Sunday
Evenings
Support Services
Please could you let us know of any support or other services which are in place and which we may need to take into consideration when considering work placements.
Day Services please
Domiciliary care Support worker Personal Assistant
Respite
Other
Benefits
If you are aware of any benefits this person is in reciept of please let us know.
Employment Support Allowance (ESA)
Incapacity Benefit (IB)
Income Support (IS)
Job Seekers Allowance (JSA)
Independent Living Fund (ILF)
Disability Living Allowance (DLA)
Other
Medical, Physical and Sensory
Please let us know if there are any concerns or issues experienced by this person. This is to ensure that we are able to assess in inappropriate setting and consider if there is any specialist equipment that maybe required to support this person into employment.
Behavioural issues risk and concerns
Please let us know if there are any identified risks or concerns which we would need to know about which may impact on the way we assess this individual or the employment settings that we consider.
Other supporting information
There may be occasions where we need to prioritise cases which we take on. If there is any further information that you feel is relevant please let us know.