Employer Referral

DurhamEnable strongly believes that referrals into our service should be made with the relevant consent provided by all parties. Please take the time to make this referral in partnership with your employee.

If this is not possible, please be aware that we will need to gain the relevant consent to service before progressing referrals.

If you require support from DurhamEnable to approach the topic of Retention Support with your employee, please contact Durhamenable@durham.gov.uk

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Consent for referral:

Is your employee aware of this referral?

• Yes
• No

Was this referral made with your employee present?

• Yes
• No

What has prompted this referral to be made?

Personal details of the referrer

Employer name: *

Address:

Employer House number / Street: *

Employer Town/City: *

Employer Postcode: *

Contact number: *

Email: *

Personal details of the person being referred:

Name: *

Preferred name: (If different from above) *

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

Address:

House number / Street: *

Town/City: *

Postcode: *

Date of Birth: *

National Insurance Number: (Optional, this information will be required to progress referrals onto service).

Contact number: *

Email: *

For DurhamEnable 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 DurhamEnable to store their information? *

• Yes
• No

Information about your employee's health/disability:

DurhamEnable is a supported employment service; we support people who have a range of disabilities and/or health conditions such as Learning difficulties, Learning Disabilities, Mental Health conditions, physical and/or sensory impairments, Neurodiversity, or other health conditions. Which of the below statements applies to your employee? Please tick all that apply. *

• ADHD
• Autism
• Cancer
• Chest of breathing problem, asthma or bronchitis
• Chronic pain of fatigue condition, e.g. fibromyalgia or ME
• Dementia, e.g. Alzheimer’s disease
• Depression, stress, anxiety or any other mental health condition
• Diabetes
• Difficulty in hearing
• Difficulty in seeing
• Epilepsy
• Heart, blood or blood circulation condition
• Joint, bone or muscle condition
• Learning difficulty, e.g. dyslexia or dyspraxia
• Learning disability
• Skin condition, severe disfigurement or allergy
• Speech impediment
• Stomach, liver, kidney, or digestive problem
• Other health conditions or disability (Please enter below)
• Other progressive health conditions (Please enter below)

Other

Your employee's current situation:

Tell us about your employee’s job role (please provide brief details about your employee’s job role) *

What are their contracted hours? *

Please describe some of the challenges your employee is facing at work *

What steps have been made by you and your employee to improve their situation? *

• Attendance Management Interviews
• Occupational health referral
• Access to Work referral
• Phased returns
• Previous In-work Support and/or application of reasonable adjustments
• None
• Other

If other, please state below:

What support do you think will help your current situation? *

• In-work support
• Training for your organisation
• Support to increase their hours
• Support to increase their level of responsibility
• Unsure
• Other

If other, please state below:

Extra information:

Please highlight 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. (e.g employment history, current support network, health condition, risks.)

How did you hear about us? *

• Colleague
• Employee
• HR department
• Industry professional
• Industry publications
• Networking events
• Social media
• Word of Mouth
• Other employer
• Durham County Council
• Other

Signatories:

Signed by referral partner *

Date *

Submit