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Employment Support Referral Form
Welcome to Employ-Ability
Email
This field is for validation purposes and should be left unchanged.
Details of person being referred/self-referral:
Title
Mr
Mrs
Miss
Dr
Other
Name
(Required)
First
Last
Date of birth
(Required)
Day
Month
Year
Gender
(Required)
Male
Female
Other
Gender other
Address
(Required)
Postcode
(Required)
Home tel
Work tel
Mobile
(Required)
Email
(Required)
Details of person making referral
Referring organisation type
(Required)
Primary Care Network/ GP
Community Support Agency
Jobcentre
Self-referral (if you are referring yourself to the service)
Secondary Health Care service
Name and Job Title (If applicable) of individual making referral
(Required)
Please put in Client’s GP surgery name and address
Referrer phone contact number :
(Required)
Relationship to person being referred:
(Required)
Referrer Notes (Please indicate what type of support the client requires):
(Required)
Initial details required
Are you or is the person you are helping to refer aged 18 or over?
(Required)
Yes
No
Do you (or does the person you are helping to refer) live in Essex (not including London boroughs such as Romford, Ilford and Barking), Southend or Thurrock or West Suffolk?
(Required)
Yes
No
Which district do you live in?
Does the person being referred currently have paid employment?
(Required)
Yes
No
If in employment has the person being referred been in that employment for longer than 3 months?
(Required)
Yes
No
Do you, or does the person you are referring, have a disability and/or long-term health condition?
(Required)
Eg. ADHD; Autism; Chest or breathing problem (Asthma or Bronchitis); Depression, stress, anxiety or other mental health condition; joint, bone or muscle condition; Learning difficulty (Dyslexia or Dyspraxia).
Yes
No
Do you, or does the person you are referring, fall into one of the following defined groups?
(Required)
Person on probation, Carer or Ex-Carer, Homeless Person, Former member of Armed Forces, Alcohol or drug dependency, Care experienced or Care Leaver, Refugee, Resettled Afghan, Person on Ukrainian Scheme, Victim or survivor of domestic abuse, young person at risk, victim of Modern Slavery
Yes
No
If in employment does the person being referred work 18 hours per week or more on average?
(Required)
Yes
No
Please detail any long-term health condition or which defined group you fall into.
Consent declaration:
Consent
(Required)
I confirm that the person being referred has given consent for a referral to be made to the IPS Service and has consented to the information contained in this referral form to be supplied to the relevant delivery provider
Do we have consent to leave a voicemail for the client?
(Required)
Yes
No
Referrer Full Name
(Required)
First
Last
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About us
Leadership Team
Our Trustees
Our story
Join us
Resources
Our services
Support for young people
Help getting back into Employment
Help with your current job
Our impact
Client Stories
A journey to recovery and success
Client Testimonial; back to basics
The difference Employ-Ability makes
Employer Stories
Providing and invaluable service
Coaching and Support
Maintaining Employment
Get in touch
General Details
Feedback
Referral
Donate
facebook
linkedin
instagram
phone
email
