Project

Referrer

Referrer Details

Title*

First name(s)*

Name*

Sex/Gender*

Date of Birth*

NI Number

Address*

Town*

County*

Postcode*

Main Telephone No.*

Email Address (Main)*

GP Surgery

Is the Participant (Or You if You Self-Referred) engaged with a job centre?

Ethnic Group*

How did you hear about Workwell?

Current Employment Situation

Are You currently engaged with the Benefits system?

Do you consider yourself to have a long-term Health Condition or Disability that limits your ability to work?

Do you consider yourself to have a short-term illness and expecting to return to fitness to be able to work?

Are you currently receiving any treatment from hospital or GP?

Are you currently involved with any rehabilitation support?

Are you currently being supported by any other employment or training support programme?

I have read and understood the Workwell privacy notice and give permission for my personal data to be stored and used in a secure manner as described*

* Age UK Cornwall & Isles of Scilly is committed to protecting and respecting your privacy and security. Whenever you provide us with your personal information via our website "Site(s)", we will treat that information in accordance with our privacy policy, our terms and conditions and current UK Data Protection legislation. By using the Site and any services we offer via our Site, you are agreeing to be bound by this policy.

To understand our views and practices regarding your personal data and how we will treat it, please read our full Privacy Policy*

I confirm that all evidence provided is genuine and that any copies are true copies of the originals and that the support offered by the project may be affected if any of the details provided are incorrect.*

I agree that based on the support provided to me, the project may offer interventions from more than one organisation (delivery partner or training provider) who are part of the WorkWell. I consent to my details being shared with relevant other delivery partners or training providers where an intervention will assist me in achieving my goals.  If this happens, I will be made aware of it at the time.*

Participant Name*

Form Submission Date*