Client Details | * compulsory fields

Date *		Date of Birth
Name *		Address *
Phone
Ethnicity		Mobile
Email

Referrer Details | * compulsory fields

Name *		Phone
Agency/Service *		Address *
Email *

Work & Income Details | * compulsory fields.  Please check box if client receiving benefit

Work and Income Number *		Work & Income Case Manager
Work and Income Office *		Phone Number
Benefit Type *

Other Details | * = compulsory fields

Disability Diagnosis or Barriers to Employment *
Other Disability Agencies Involved
Disability 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 *
Relevant Details *

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?
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?
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.




3. | If the client has clearly identified a specific job choice will they need training before accessing our service?
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?