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Working Denbighshire referral form
Is this form being filled out by a member of an Agency?
Name of Agency
Agency Staff Name
Agency Email Address
Who is filling in this form?
Date Referred
Identity
National Insurance Number
Title
Please select
Mr
Mrs
Miss
Ms
First Name(s)
*
Surname
*
Contact Details
Address Line 1
*
Address Line 2
*
Town
*
Postcode
*
Preferred Language
Please select
Welsh
English
Contact Telephone
*
Alternative Telephone
Email Address
*
Characteristics
Date Of Birth
*
Gender
Please select
Male
Female
Migrant Status
Please select
Yes-EU
Yes-non-EU
No
Work Limiting Health Condition
Please select
Yes
No
Information Refused
Disability
Please select
Yes
No
Information Refused
From BME background?
Please select
Yes
No
Information Refused
Employment and Benefits
Employment Status
If Employed Are You Under Employed
Please select
Long-term unemployed
Short-term unemployed
Economically inactive
Under-employed
Self-employed
Employed
EnumFullTimeEducationTraining
NEET
How long have you been unemployed?
Please select
0 - 6 Months
7 - 12 Months
1 - 2 Years
3 - 5 Years
5+ Years
Never worked
Benefit:
Duration Of Benefit Claim or Time Spent Economically Inactive(Months)
Universal Credit Regime
Number of Hours Worked Per Week
If you are affected by any of the issues below please let us know so we can tailor support to suit you.
Homeless Or Affected By Housing Exclusion
Under 25 And At Risk Of Becoming NEET (Not in Education or Training)
Low or no skills
Mental Health Concerns
Single adult household
Impacted By Redundancy
Financial Or Debt Concerns
Difficulty In Engaging In EET (Education Employment or Training)
Ex Offender Or Supported By YJS (Youth Justice Service)
Domestic Abuse
Substance Abuse
Social Isolation
Asylum Seeker
Neither Welsh Nor English As Your First Language
Jobless Household
Looked After Child Or Care Leaver
Carer
Please select
None
Primary Carer of a child/children (under 18)
Primary carer of disabled adult (18 and over)
Primary carer of older person/people (65 and over)
Careers Wales Only
Careers Wales Tier
Please select
Tier 0
Tier 1
Tier 2
Tier 3 (90 days or more)