Client Referral Form
Before entering any client data, please confirm that she meets the criteria to receive support from Working Chance.
All boxes must be ticked to indicate that the client meets our criteria. If you're unsure or would like to discuss a potential referral, please contact firstname.lastname@example.org
Is aged 18+, has at least one conviction or caution and identifies as a woman (or non-binary)
Is eligible to work in the UK and has documents to evidence this along with photo ID
Is work-ready and able to consistently commit to engaging with Working Chance
Is able to engage independently and has basic literacy and IT skills (qualifications not required)
Is able to manage any mental health issues
Has been free from any alcohol or substance dependency for at least 3 months (including substances such as methadone)
Is able to demonstrate reasonable responsibility for the crimes she’s been convicted of
Has regular private access to internet, a personal email address and telephone
Please complete this referral form in as much detail as possible. Should you have any questions, please contact Working Chance at the following email address: email@example.com
Include borough where applicable
Previous or Alternative Name(s)
Date of Birth
Enter as DD/MM/YYYY
Is it safe to the leave the client a message?
We can only accept referrals with a valid client email address, otherwise please email firstname.lastname@example.org
Support Needs & Risk
Please use this space to tell us about any support needs or risks we should be aware of.
Please include, if applicable, any other relevant information that you or the client would like us to be aware of.
Please tick here to confirm that the client has authorised you to submit this referral on their behalf and that they are happy to be contacted by Working Chance.