Referral Form - March 2026

1: Title 
Title must be provided  Select only one Title 
Title
2: First name 
First name must be provided
3: Last name 
Last name must be provided
4: Date of birth 
Date of birth must be provided
You must be at least 16 years old to register
Date of birth *
For example, 31 3 1980
5: Contact number 
Contact number must be provided
6: Email address 
Email address must be provided
11: Postcode 
Postcode must be provided
12: What is the residents current employment status? 
What is the residents current employment status? must be provided  Select only one What is the residents current employment status? 
What is the residents current employment status?
13: Do they have the right to work in the UK?  
Do they have the right to work in the UK? must be provided  Select only one Do they have the right to work in the UK?  
Do they have the right to work in the UK?
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14: What is your current immigration status? 
What is your current immigration status? must be provided  Select only one What is your current immigration status? 
What is your current immigration status?
15: Are they currently attending/working with any other employment support services/programmes? 
   
Are they currently attending/working with any other employment support services/programmes?
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16: If yes, please provide details of other employment support services/programmes? For example, Restart 
  Select only one If yes, please provide details of other employment support services/programmes? For example, Restart 
If yes, please provide details of other employment support services/programmes? For example, Restart
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17: Please provide details of types of roles/sectors the resident is interested in 
  Select only one Please provide details of types of roles/sectors the resident is interested in 
Please provide details of types of roles/sectors the resident is interested in
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18: Please select any areas of employment support required 
  Select only one Please select any areas of employment support required 
Please select any areas of employment support required
19: What is the residents highest level of qualification? 
What is the residents highest level of qualification? must be provided  Select only one What is the residents highest level of qualification? 
What is the residents highest level of qualification?
20: Do they have Entry Level, Level 1 or Level 2 qualifications in Maths and English (or ESOL for those with English as second language)? 
Do they have Entry Level, Level 1 or Level 2 qualifications in Maths and English (or ESOL for those with English as second language)? must be provided  Select only one Do they have Entry Level, Level 1 or Level 2 qualifications in Maths and English (or ESOL for those with English as second language)? 
Do they have Entry Level, Level 1 or Level 2 qualifications in Maths and English (or ESOL for those with English as second language)?
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21: Gender 
Gender must be provided
22: Ethnicity 
Ethnicity must be provided
23: Details on any convictions 
  Select only one Details on any convictions 
Details on any convictions
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24: Do they have any special educational need, disability, long term health condition or impairment? 
Do they have any special educational need, disability, long term health condition or impairment? must be provided  Select only one Do they have any special educational need, disability, long term health condition or impairment? 
Do they have any special educational need, disability, long term health condition or impairment?
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25: If yes, please provide further information 
  Select only one If yes, please provide further information 
If yes, please provide further information
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26: If this resident is a young person aged 16-25, do they currently have an active EHCP? 
  Select only one If this resident is a young person aged 16-25, do they currently have an active EHCP? 
If this resident is a young person aged 16-25, do they currently have an active EHCP?
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27: Name of person completing referral 
Name of person completing referral must be provided  Select only one Name of person completing referral 
Name of person completing referral
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28: Role of person completing referral 
Role of person completing referral must be provided  Select only one Role of person completing referral 
Role of person completing referral
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29: Name of service/organisation completing referral 
Name of service/organisation completing referral must be provided  Select only one Name of service/organisation completing referral 
Name of service/organisation completing referral
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30: Are you the primary person supporting this resident? 
Are you the primary person supporting this resident? must be provided  Select only one Are you the primary person supporting this resident? 
Are you the primary person supporting this resident?
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31: If no, please provide details of key worker 
  Select only one If no, please provide details of key worker 
If no, please provide details of key worker
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32: Will the primary person/key worker continue to support the resident once referred? 
Will the primary person/key worker continue to support the resident once referred? must be provided  Select only one Will the primary person/key worker continue to support the resident once referred? 
Will the primary person/key worker continue to support the resident once referred?
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33: Please provide details of other professional and services suporting the resident 
  Select only one Please provide details of other professional and services suporting the resident 
Please provide details of other professional and services suporting the resident
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34: Please provide any further information on the resident that you feel is resident 
  Select only one Please provide any further information on the resident that you feel is resident 
Please provide any further information on the resident that you feel is resident
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* Data Protection Notes


I declare that to the best of my knowledge the information given on this form is correct and have consent to share this information with Work Hounslow. You are providing your information to Hounslow Council, contact details work@hounslow.gov.uk or 020 8583 6174. The Council’s Data Protection Officer can be contacted via informationgovernance@hounslow.gov.uk.The details will be stored securely and retained in compliance with the GDPR and the information shall be retained for up to seven years and shall be processed in adherence to your legal rights, including but not limited to the right to withdraw consent, right to copies of their information and right to be forgotten. Service users have the right to lodge a complaint with the Information Commissioner’s Office (www.ico.org.uk).Further information can be found at https://www.hounslow.gov.uk/info/20110/open_data_and_information_requests/1368/privacy_notice.If you have any concerns about the storage and use of your data please contact Work Hounslow at work@hounslow.gov.uk.
Do you agree to the data protection terms and conditions?
Client:
Date: ......................... Signed: .......................................
Caseload:
Date: ......................... Signed: .......................................