Referral

Employment Services Referral

Referral Requirements

This form is for referrals to our free employment support service and must be completed by a health professional, support worker, or Work and Income representative.

To be eligible, jobseekers must:

Be receiving a Work and Income benefit
Be aged 16–64 years
We strongly recommend jobseekers have at least one referee at the time of referral to improve work readiness and employment opportunities.

Referral Form

Personal Details

Legal Name:

Date of Birth:

Pronouns:

Address:

City:

PostCode:

Phone:

Mobile:

Email:

Ethnicity:

Emergency Contact:

Emergency Contact - Relationship to Jobseeker:

Emergency Contact - Phone Number:

Referrer Details

Name:

Referring Agency/Service:

Address:

Phone:

Mobile:

Email:

Medical Details

GP Name:

GP Practice:

Benefit Type (Must be receiving a Work and Income Benefit to proceed.):

Work and Income Number:

Additional Details

Does the person have a CV? If yes, please bring it to first appointment.:

Upload a Copy of your CV (optional): Choose FileNo file chosen

Do they have up to date references? (At least one work reference or volunteer reference):

Is the person you are referring already in work? If yes how many hours?:

Must not be working over 5 hours per week to access service::

What sort of the job is the person looking for?:

Disability or Challenges to Employment (disability must be stated for referral to proceed):

Do you have any criminal convictions? Yes No

Are you currently on probation? If yes, we recommend contacting your Probation Officer for employment support, as this falls outside the scope of our service Yes No

Any other comments:

Security: Security Code