Referral : Welcome

Welcome to the North East North Cumbria Work Well Service!
Please submit the following details in order to make a referral into Work Well. This information will be sent electronically to our multi-disciplinary Team who will review your request and then get in touch.

Please fix the following issues before continuing:

View Rights and Information Sheet here.

Consent to record information *

Yes

Title *

First Name *

Surname *

Date of Birth *

Medical Gender

Female

Male

Non-Binary

Transgender Female

Transgender Male

Address (Street) *

Address (Town/City) *

Address (County) *

Postcode *

Email *

Email allowed *

Yes

Mobile *

SMS allowed? *

Yes

Tel

Preferred contact method *

Phone

SMS

Emergency contact relation *

Emergency contact name *

Emergency contact telephone number *

NHS No

GP registered

Unregistered

Registered

GP Details

My GP isn’t listed

Learning Disability

Yes

Prefer not to say

- If Yes

Highest Education Level *

Are you currently involved with the Criminal Justice System? (Probation, community order, licence conditions under the Offender Rehabilitation Act 2014.) *

Yes

If yes, brief details:

Are you supervised by Probation or Youth Justice (Covered by the Offender Rehabilitation Act 2014 and Criminal Justice Act 2003.) *

Yes

Reason for Referral into WorkWell *

- If Other

Please provide details on referral *

Referral Source *

- If Other

Referring organisation *

Referrer Name

Referrer Telephone Number

Referrer E-Mail Address

How did you hear about WorkWell?

- If Other

Consent to Share Information -: With your consent, we may share your information with another employability programme (such as Connect to Work) if we believe it may better support your needs. This helps avoid duplicate referrals and ensures a smooth transition between services. Only relevant information will be shared, and you can withdraw your consent at any time. To provide your consent, please write your full name in the box:

Yes, I consent to my information being shared with other employability support programmes for this purpose.

By providing your full name, you confirm that you consent to the sharing of your information as described above. This consent is optional. If you do not fill in your name, your information will not be shared with other organisations, and you can still receive support from Work Well.

North East North Cumbria Referral Form