Self referral form | WorkWell Referral Form

WorkWell Referral Form

If you have any questions or queries, please contact the team on: 0800 952 6955
WorkWell is an early intervention programme to support people who are employed and recently unemployed with health conditions and disabilities to start, stay or succeed in work.

Eligibility Criteria:
WorkWell is available for anyone who is:

16+ years old
Lives or is registered to a G.P.or local Jobcentre Plus falls anywhere within the Black Country
Has the right to work within the UK
Anyone experiencing barriers to employment due to health conditions/disabilitiest

WorkWell will support those who are in work, need support returning to work or are out of work up to 6 months who require early intervention due to facing health related barriers, however, we also link participants needing more complex support to return to work who have been out of work longer with services who can provide longer term support.

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Referrer Details

Referrer Name:

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Referrer Contact Number:

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Email Address:

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Organisation / Relationship to Participant:

Participant Details

Title:

First Name: *

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Last Name: *

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National Insurance Number (if known):

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Date of Birth: *

Gender: *

Mobile Phone Number *

Home Phone Number

Work Phone Number

Email Address:

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Email Consent:

Yes

Address Line 1 *

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Address Line 2

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Address Line 3

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Town/City *

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Post Code *

Consent to Post correspondence:

Yes

Preferred Method of Contact: *

GP Surgery

Referral Information

Please select the relevant statement that apply to you: *

Other relevant statement – Please Specify:

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Risks & Adaptations? (Please provide as much information as possible on potential risks or adaptations WorkWell Coaches should be aware of for the participant) *

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What Support Does the Participant Require?
Support with confidence
Support managing a condition
Return to work support
Links to services in the community *

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Is the particpiant currently receiving any other support from Employment services (if yes please specify)

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I would like to receive a confirmation of the referral to the email address I specified above. Please check the spam folders within your email if you do not receive a confirmation in your inbox.

I accept terms and conditions. *

Contact Telephone: 0800 952 6955

Contact Email: bchft.workwellteam@nhs.net