Download btg-referral-form

Bridge the Gap
Exploring Aspirations
Bridge the Gap Referral Form
Client Name:
Name of your organisation:
Date of Birth:
Client Telephone Number:
Does your client want to progress towards work readiness?
Y
N
Y
N
Y
N
Y
N
Y
N
(Please circle N or Y as applicable) (or If e-mailing delete as applicable)
Does your client have support needs that would be helpful for use to know about? (Please include drug or
alcohol misuse, mental health issues, offending and whether the client is on a support programme) PLEASE
NOTE: If you have a risk assessment in place for your client and consent to share, please provide a copy of this
to help us with our own risk management of the programme.
Does your client have a record of sexual offending?
If yes please give brief details:
Is this client considered to be potentially violent?
If yes what are the triggers to violence?
What feedback / monitoring information do you require/would be useful from us?
Is your client happy for the Bridge the Gap worker to contact them directly to arrange an initial appointment?
Your name:
Date:
Signature [Omit if e-mailing] :
Telephone:
Email:
Thank you for completing this form and for your referral. I will contact you and/or your client on receipt of this form to arrange an
appointment.
Please note that these questions are designed to ensure that we have the information we need to ensure your client has a positive
experience on the Bridge the Gap programme. However, if this programme is not suitable for your client we will aim to help find
alternative provision which better meets their needs.
Please return this form to me as quickly as possible to the following contact: Email: [email protected] or Tel:
07775 704282
Hard copy by post to: Maddy Collins, Bridge the Gap, Pathways to Employment, New Street Centre, 1 New Street, St Judes,
Bristol, BS2 9DX.