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DWP / LEP Referral Form

Customer Referral to Discover Work

We are completing this form following discussion and agreement with the below named individual, for referral to local authority employability support.

Name

Address (including postcode)

Date of birth

N.I. Number

Tel. Number

Benefit Type

Start Date

Benefit Type

Start Date

Employment Status

Unemployed (JSA, ESA WRAG or UC Intensive Work Search) Economically Inactive (Not actively looking for work e.g. UC No Work-Related Requirements, Work Focussed Interview, Work Preparation or ESA (except WRAG) Employed (UC Working Enough, Light Touch or Self Employed)

Participant Circumstances (Please select all that apply)

Armed forces veteran Care experienced Criminal Conviction Disability or Health Condition Ethnic minority Lone parent Long term unemployed Migrant/ Refugee No or limited work experience Parent/ carer of child under 18 Resident in lowest 15% SIMD Substance related conditions

Reason for referral

Pre-employability Adult Literacy and Numeracy Employability English for speakers of other languages (ESOL) In-work support Health/ Supported Employment

Suggested provision

Contact Person

Position

Signature

Phone

Date

Declaration

I confirm that all the information on this form has been verified through primary and secondary evidence checks where required.

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