Career Moves
Level 2,
London Business Centre
55 London Street
HAMILTON
Phone (07) 839-7367
Fax
(07) 839-1668
[email protected]
Supported Employment Referral Form
Important: please answer all questions
Are you are filling this referral form out for yourself?
yes
no
Has consent been given to make this referral?
yes
no
(if no to above)
not applicable
Have the person’s family/whanau/caregiver been informed of this referral?
yes
no
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Date of referral _________________
Name
____________________________________________________________
Address Street
________________________________________________
Suburb
________________________________________________
Town/City
___________________________Post Code: _____________
Telephone______________________________Mobile_________________________
Email __________________________
Date of birth ____________________________
Age _______________
Place of Birth ______________________________
Ethnicity
Maori
Pakeha
Pacific Islander
Other (Please specify) ______________________________
Do you have?
New Zealand Citizenship
WINZ Client Number
Residency
Open Work Permit
None of these.
_________________________________
Services that are important to include in this supported employment referral
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 Supported Living provider
_____________________
ph. ____________
(name and contact)
Are they aware of this referral?
yes
 Vocational support provider
no
____________________
ph. ___________
(name and contact)
Are they aware of this referral?
yes
no
 Other provider of services/ support ___________________
ph. __________
(name and contact)
Are they aware of this referral?
yes
no
Other services involved
Department of Work and Income
Workbridge
ACC
Disability Support Link
Other (Please list)___________________________________________________
What is the reason for this referral?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
What type of ongoing support would you require if you were to find a job?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
What work history do you have?
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
What disability do you have?
Intellectual
Physical
Sensory
Psychiatric
Other/Specifics ____________________________________________________
Do you receive a benefit from Work and Income?
Yes
No
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If ‘Yes’, please state which benefit.
Do you have any individual or cultural needs we should be aware of for your
Referral Interview?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Name of referrer if different from person being referred
___________________________________________________________________
Relationship to person being referred
_____________________________________
Address: Street
________________________________________________
Suburb
________________________________________________
Town/City
________________________________________________
Telephone______________________________
Email __________________________________
Office Use Only:
Date Referral received________________________________________________
Services consulted with _______________________________________________
Eligibility Meeting Date:_______________________________________
Date Referral Interview Emailed/ Phoned/ letter sent___________________________
Date for Referral Interview_____________________________________________
Outcome of Referral Interview: Registered on Job Seeker’s Register
Referral Withdrawn
Other ___________________________________________________________
Date Referral Outcome is notified________________________________________
Date client begins service______________________________________________
Clients File Name____________________________________________________
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