Work Hounslow Referral Form

Hounslow Council service teams, partners and local organisations can complete the form to refer residents you are supporting in the borough to Work Hounslow. We provide free employment support, including job searching, access to pathways into training or work and more, to residents aged 18 and above who are unemployed and not in education or training. This includes residents with special educational needs and disabilities (SEND), care-experienced young people and those who have been involved in the Youth Justice System. For further information, contact us at

Resident Details

1: Title 
Title must be provided  Select only one Title 
Title
2: First name 
First name must be provided
3: Last name 
Last name must be provided
4: Date of birth 
Date of birth must be provided
You must be at least 16 years old to register
Date of birth *
For example, 31 3 1980
5: Contact number 
Contact number must be provided
6: Email address 
Email address must be provided
11: Postcode 
Postcode must be provided
12: What is the current employment status of this resident? 
What is the current employment status of this resident? must be provided  Select only one What is the current employment status of this resident? 
What is the current employment status of this resident?
13: Gender 
Gender must be provided
14: Ethnicity 
Ethnicity must be provided
15: If this resident is a young person aged 16-25, do they currently have an active EHCP? 
  Select only one If this resident is a young person aged 16-25, do they currently have an active EHCP? 
If this resident is a young person aged 16-25, do they currently have an active EHCP?
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16: Name of person completing referral 
Name of person completing referral must be provided  Select only one Name of person completing referral 
Name of person completing referral
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17: Role of person completing referral 
Role of person completing referral must be provided  Select only one Role of person completing referral 
Role of person completing referral
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18: Name of service/organisation completing referral 
Name of service/organisation completing referral must be provided  Select only one Name of service/organisation completing referral 
Name of service/organisation completing referral
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19: Are you the primary person supporting this resident? 
Are you the primary person supporting this resident? must be provided  Select only one Are you the primary person supporting this resident? 
Are you the primary person supporting this resident?
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20: If no, please provide details of key worker 
  Select only one If no, please provide details of key worker 
If no, please provide details of key worker
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21: Will the primary person/key worker continue to support the resident once referred? 
Will the primary person/key worker continue to support the resident once referred? must be provided  Select only one Will the primary person/key worker continue to support the resident once referred? 
Will the primary person/key worker continue to support the resident once referred?
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22: Please provide details of other professionals and services supporting the resident 
  Select only one Please provide details of other professionals and services supporting the resident 
Please provide details of other professionals and services supporting the resident
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23: Please provide any additional support about the resident that may be useful for us to support them 
  Select only one Please provide any additional support about the resident that may be useful for us to support them 
Please provide any additional support about the resident that may be useful for us to support them
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* Data Protection Notes


I declare that to the best of my knowledge the information given on this form is correct and have consent to share this information with Work Hounslow. You are providing your information to Hounslow Council, contact details work@hounslow.gov.uk or 020 8583 6174. The Council’s Data Protection Officer can be contacted via informationgovernance@hounslow.gov.uk. The details will be stored securely and retained in compliance with the GDPR and the information shall be retained for up to seven years and shall be processed in adherence to your legal rights, including but not limited to the right to withdraw consent, right to copies of their information and right to be forgotten. Service users have the right to lodge a complaint with the Information Commissioner’s Office (www.ico.org.uk). Further information can be found at www.hounslow.gov.uk/info/20110/open_data_and_information_requests/1368/privacy_notice. If you have any concerns about the storage and use of your data please contact Work Hounslow at work@hounslow.gov.uk.
Do you agree to the data protection terms and conditions?
Client:
Date: ......................... Signed: .......................................
Caseload:
Date: ......................... Signed: .......................................