Trainee Referral FormInterested in working together? Fill out some info and we will be in touch shortly! Your Details Name * First Name Last Name Date of Birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone (###) ### #### National Insurance Number Emergency Contact Details Name * First Name Last Name Relationship * Emergency contact phone * (###) ### #### Emergency contact email * Referral Agency Details (if applicable) Organisation / agency name Name First Name Last Name Relationship to client Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email Phone (###) ### #### Background Details Reasons for referral * Why do you wish to come to/refer this individual to Giraffe? What outcomes are you hoping will be achieved? Current employment/education status: * What is your/the individual’s current employment/education status? Support needs * Please tell us about any additional support needs, giving as many details as possible Do you/the individual have a condition/disability which is covered by the Equalities Act? * Yes No If yes to the above, please give details, including any reasonable adjustments that you think would be appropriate. o you/the individual have any mental health and well-being needs or challenges? * Yes No If yes to the above, please give details Are you/the individual currently being supported by any other agencies? * Yes No If yes to the above, please give details Do you/the individual require one-to-one support? * Yes No Do you/the individual have any issues with addiction? * Yes No If yes to the above, please give details Have you/they been referred for support/counselling? * Yes No Offending History Do you/the individual have any history of offending? * Yes No If yes to the above, please give details of last conviction (and any unspent conviction) Date of last conviction MM DD YYYY Length of sentence Any other details which may be relevant to working with young adults (16-18) and/or vulnerable adults: Is there a risk of the individual re-offending? Yes No If yes, please rate level of risk Low Medium High Declaration PLEASE CONFIRM: * The information which has been provided in this form is complete and accurate to the best of my knowledge. (Please note that all information provided on this form will be collected and stored under the Data Protection Act 1998.) Yes Name First Name Last Name Thank you!
