Making a Referral

We can support you if you:

• are unemployed
• live in County Durham
• are aged 18 or over
• are facing barriers to employment because of a learning disability, autistic, neurodivergent, mental health need, or other long term health condition

You can make a self-referral or someone can do so on your behalf, such as a family member, social worker, or carer.

Once we have received your referral, we aim to contact you within two weeks of receiving your referral to set up an initial meeting and register you to service.

Registering with us does not impact your benefits.

To begin a referral for yourself or someone you know, you can fill in the form below.

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Personal details

Name *

Please provide details of the person you would like to refer.

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: *

Contact number:

Email *

Referral partner details:

Referrer name: *

Organisation:

Contact number:

Email *

Who would you like us to contact about your referral? *

• The person being referred
• Someone who can speak for person being referred. (Please provide details below)

If someone else, please provide their contact details. (This should be someone you trust and who can talk about your health)

What is your preferred method of communication? *

• Text
• Telephone call
• Email
• WhatsApp
• Video call

For DurhamEnable to process this referral, the information needs to be stored on a secure database. This is so we know how to contact jobseekers 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

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 you? Please tick all that apply. *

• Learning Difficulty
• Learning Disability
• Autism/Neurodiversity
• Mental Health Condition
• Physical and/or sensory impairments
• Health condition

Other disability: (please describe)

How early is it reasonable to start looking for work? Please select one of the following.

• 1-3 months
• 3-6 months
• 1 year or more

As a supported employment service, we can offer you a range of support. Which of the following can we support you with? Please tick all that apply.

• Education
• Employment
• Personal & social development
• Self-employment
• Skills development
• Training
• Volunteering
• Other

If other, please state below:

Welfare Support: Are you in receipt of any of the following benefits?

Job Seekers Allowance (JSA) *

• Yes
• No
• Unknown

Employment Support Allowance (ESA) *

• Yes
• No
• Unknown

Universal Credit (Replaces income-based JSA, income-related ESA + income support) *

• Yes
• No
• Unknown

PIP – Daily Living part *

• Yes
• No
• Unknown

PIP – Mobility part *

• Yes
• No
• Unknown

Other (Please state):

Labour Market Status:

How long has the person been unemployed for?

Is the person actively searching for work?

• Yes
• No
• Unknown

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)

Signatories

Signed by referral partner

Date

Submit