Work Wise  referral form.

Work Wise is a free employment service available to any person with a mental or physical health condition, disability, or neurodivergence, who wants to work.

Fill out our form and one of our expert employability specialists will contact you to discuss the next steps.

Are you referring yourself? *YesNo

First name. *

Last name. *

Email address. *

Phone number. *

How did you hear about us? *Please select oneFacebook / Instagramwww.gov.ukCommunity organisationsFriend/familySurrey County CouncilProvider outreach activityMy employerWork Wise promotional materialsStrategic Migration PartnershipsOther

Postcode. *

Translator required. *YesNo

If Yes, what language?

Are you aged 16+? *YesNo

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

What is your health condition or disability?Please select oneSensory impairmentRecurring or fluctuating conditionProgressive and/or chronicAuto-immuneOrgan specificDevelopmentalLearning disabilityMental health conditionRestrictions arising from bodily injury, including to the brainOtherMore than one of the above

Please use this box if you want to provide further relevant details of your health condition or disability.

Professional referral.

Please fill in this section with your information.

Referrer name? *

What organisation are you referring from? *

What is your organisation address? *

What is your email address? *

What is your phone number? *

How did you hear about us?Please select oneFacebook / Instagramwww.gov.ukCommunity organisationsFriend/familySurrey County CouncilProvider outreach activityMy employerWork Wise promotional materialsStrategic Migration PartnershipsOther

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 email address? *

What is their phone number? *

Do they require a translator? *YesNo

If Yes, what language?

Are they aged 16+? *YesNo

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

What is their health condition or disability?Please select oneSensory impairmentRecurring or fluctuating conditionProgressive and/or chronicAuto-immuneOrgan specificDevelopmentalLearning disabilityMental health conditionRestrictions arising from bodily injury, including to the brainOtherMore than one of the above

Please use this box to provide further relevant details of their health condition or disability.

Submit

Please do not fill in this field.