IPS Work Your Way referral form

IPS Work Your Way is a new support service delivered by Get Set UK on behalf of Essex County Council.

Fill in our form and a member of our team will get in touch to discuss how our fully funded service can help you find and keep the right job.

Are you referring yourself? *YesNo

First name *

Last name *

Email address *

Phone number *

How did you hear about us? *Please select oneCommunity organisationsFriend/familyEssex County CouncilProvider outreach activityIPS Work Your Way promotional materialsOther

Postcode *

Translator required? *YesNo

If yes, what language?

Are you aged 18+ *YesNo

Are you currently in paid employment (Full-time, part-time or temporary)? *YesNo

Please use this box to indicate any support required and any information relevant to your mental/physical health condition..

I agree that the information above is correct*

Professional referral

Please fill in this section with your information.

Referrer name? *

What organisation are you referring from? *

What is your email address? *

What is your phone number? *

How did you hear about us?Please select oneCommunity organisationsFriend/familyEssex County CouncilProvider outreach activityIPS Work Your Way promotional materialsOther

Questions about your client.

This is a referral for a client. All the below questions refer to the client you are referring.

What is their name? *

What is their postcode? *

What is their phone number? *

What is their email address? *

Do they require a translator? *YesNo

If yes, what language? *

Are they aged 18+ *YesNo

Are they currently in paid employment (Full-time, part-time or temporary)? *YesNo

What are the details of their mental or physical health condition?

The above information is correct*

I can confirm I have consent from the individual listed to share their details*

I can confirm I have explained to the individual what data has been captured and who it will be shared with*

Submit