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Personal details of the person being referred/self-referral

Name *

Preferred pronouns (He/she/they/prefer not to say *

Address:

House number/Street: *

Town/City: *

Postcode: *

Date of birth *

National Insurance Number:

Contact Number: *

Email *

Which of the following best describes your current situation: *

• In school
• In further education
• Employed
• Not in education, employment, or training
• Other

For DurhamWorks to process this referral, the information needs to be stored on a secure database. This is so we know how to contact your employee about the service. All information is stored securely and retained in compliance with the General Data Protection Regulation (GDPR) more information can be found by visiting www.durham.gov.uk/dataprivacy. Does the person give permission for DurhamWorks to store their information? *

• Yes
• No

If you’re making a referral on behalf of someone else, please provide your details:

Name:

Job Title & Agency:

Contact number:

Email:

Please include any information about your/their health/disability:

Extra Information:

Please detail any risks associated with this person. (e.g. Self-harm, risk to self, risk to others, criminal convictions, warning, cautions, regular seizures, medical needs)

Please use the space below to provide any information you think we need to be aware of. What support you are seeking? *

Please detail benefits being claimed: *Unemployed (Claiming UC and seeking work)Unemployed (claiming UC: parent of young children; ill-health; carer)Unemployed (Claiming PIP)Unemployed (not claiming benefits)In work but employment status at risk or with no accredited trainingAt risk of disengaging from Education or TrainingAt risk of not making a successful transition into EducationYear 11

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We need to collect this information to make sure that you qualify so we can contact you with information about DurhamWorks. We will not use your information for anything else. For more information visit the Privacy Policy.