Making a Referral

We can support you if you:

• are unemployed and looking for support to overcome challenges in your role or at risk of falling out of work due to your disability and/or health condition.
• live in County Durham
• are aged 18 or over
• are facing barriers to employment because you have a learning disability/difficulty, are autistic, or neurodivergent or due to multiple complex needs.
• or belong to one of the disadvantaged groups listed below

Disadvantaged groups

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: *

National Insurance Number:

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

Do you consider that you are a disabled person or have a long-term health condition? You are disabled if you: Have a physical or mental impairment which has an impact on your ability to do day-to-day activities. OR Experience barriers which limit your ability to participate in everyday life. E.G. you face barriers such as: lack of accessible buildings, transport or printed documents, or others assuming that you cannot do things (e.g. a job) A long-term health condition means a physical or mental health condition lasting, or expected to last, 12 months or more. *

• 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. *

• 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

Which, if any, of the below defined groups fits your current situation? *

• An ex-offender (completed custodial or community sentence)
• An offender (currently serving a community service)
• A carer
• An ex-carer
• A homeless person
• A former member of His Majesty’s (HM) Armed Forces (AF), a partner of current of former Armed Forces personnel, or a member of HM AF reserves
• A person for whom a drug or alcohol dependency, including a history of dependency, presents a significant barrier to employment
• A ‘care-experienced young person’ or a ‘care leaver’ (A person with ‘care experience’ has spent time within the local authority care system living in foster care or residential care
• A refugee, a resettled Afghan
• A person on the Ukrainian scheme
• A victim/ survivor of domestic violence
• A young person identified as being involved, or at risk of being involved, in gangs or serious violence
• A victim of modern slavery
• None

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
• Unpaid work placements
• 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:

Please select an option below that best describes your current working situation: *

• I am not employed/ self-employed
• I am employed
• I am self employed

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)

How did you hear about us? *

• Jobcentre Plus
• Primary Care (GP, Practice Nurse, Allied Health Professional, Other Primary Care staff member)
• Community Care (Improving Access to Psychological Therapies, pain clinics, physio and other community care services, psychology, psychotherapy, social prescribing)
• Adult Social Care Services
• Employer
• Charity
• Advice Service
• Self-referral
• Other

If other, please provide more information below:

Signatories:

Signed by referral partner *

Date *

Submit