Job Seeker Referral Form

Referring Your Client to Our Service

Catapult accepts referral from Doctors, Work and Income, and other service providers. If you have a client who may benefit from accessing supported employment and shows a genuine motivation to look for work, please fill in the online referral form below or download the printable version here and send it in to us

Referral Form

 (Online form only, for a printable version click on the link above)

Client Details
			* = compulsory fields
Date:	*	Date of Birth:
Name:	*	Address:	*
Phone:		Mobile:
Ethnicity:

Referrer Details
Referrer Name:	*	Phone:	*
Referring Agency / Service:	*	Address:	*
Email:	*

Work & Income Details

Please check box if client receiving benefit

Other Details
Disability Diagnosis or Bariers to Employment:	*
Other Disablity Agencies Invloved
Disablity Case Manager:		Phone:
Do you have a CV?:	yes   no    If yes, please bring it with you to your appointment
Reason for referral:	*
Job Choices * If client is hoping to access Activity in the Community (AIC), or Taskforce Green, please identify	*
Relevant Issues * see Referrer Checklist (Incomplete information, including omitted behavioural or legal issues may have a negative impact on outcomes)

CATAPULT EMPLOYMENT SERVICES TRUST – REFERRER CHECKLIST
You may find the following questions helpful in deciding whether to refer your client to our service. We have found that there are many perennial issues that clients present with and you may find the following suggestions helpful in order to get the best results for your client.
1. Has the person clearly demonstrated work readiness and motivation?	yes     no
Sometimes clients with high needs may be changing their minds about work frequently or be responding to real or perceived pressure from others to find a job. To make employment a realistic option there needs to be a clear demonstration of the person wanting to work over a reasonable period of time. Sometimes clients with high needs may not be clear about what it means to work and may need some initial training around this.
2. Are there any health issues that need to be addressed before starting work?	yes     no
We work with people regardless of any health issues however we need to know there is a baseline of stability so that a person’s health will not be adversely affected by working. Please give details below.
Health situation manageable/appropriate for work?	yes     no
3.If the client has clearly identified a specific job choice will they need training  before accessing our service?	yes     no
For example if the person wants to be an Office Assistant, do they need to be enrolled in an Office Skills Course before accessing our service?
4. Are there other needs that should be addressed before the job search process can begin e.g. Housing, Budgeting, Support for Family/Whanau?	yes     no

Send to Catapult Employment Services Trust