Healthy Working Life Referral Form

Referrer’s first name

Referrer’s surname

Referrer’s email address

Referrer’s phone number

Referrer’s job title

Referrer’s employer

Candidate’s first name

Candidate’s surname

Candidate’s address 1

Candidate’s address 2

Candidate’s address 3

Candidate’s postcode

Candidate’s Date of Birth

Candidate’s email address

Ethnicity Ethnicity Which of the following options best describes your race, ethnic or cultural origin: White English / Welsh / Scottish / Northern Irish / British White Irish White East European White Other Mixed White / Black Caribbean Mixed White / Black African Mixed White / Asian Mixed Other Asian or Asian British Indian Asian or Asian British Pakistani Asian or Asian British Bangladeshi Asian or Asian British Kashmiri Asian or Asian British Other Black or Black British Caribbean Black or Black British African Black or Black British Other Chinese Roma Arab Gypsy / Traveller Other Don’t Know

Candidate’s job title

Is the candidate living with long-term pain? Is the candidate living with long-term pain? Yes No

Does the candidate have a disability? Does the candidate have a disability? Yes No

Please describe:

Is the candidate actively going into the workplace? Is the candidate actively going into the workplace? Yes No

Is the candidate working remotely? Is the candidate working remotely? Yes No

Short summary of how the candidate’s pain is affecting their work

Date of candidate’s last day at work

Please confirm that the client/customer has given consent, MUST be completed for referral to be accepted. Please confirm that the client/customer has given consent, MUST be completed for referral to be accepted. I consent to my name, contact details and personal information and the candidate’s name, contact details and personal information on this form being stored securely in compliance with GDPR requirements. Details will be stored for 60 months as outlined in the relevant privacy policy.