Into Work referral form

Into Work Referral Form

Into Work is a recovery-based service which aims to promote social inclusion through employment opportunities.

Our aim is to support you to make change, by looking at the barriers you face around your mental wellbeing. We provide you with a tailored recovery/ vocational plan, with the end goal of supporting you into paid employment.

Personal Details

First Name

Last Name

Your date of birth

You must be at least 18 years old to complete this form

Do you identify as

If 'Other' please specify

Pronouns you use

Best way to reach you

Your email

Your mobile number

Your Address Line 1

Your Address Line 2

Your Address Line 3

Your City/Town

Your Postcode

Has a mental health professional diagnosed your condition?

Yes, diagnosedNo, not diagnosed

Which of the following areas do you live in?

Gravesend, KentHarrow, London

Referral and Employment Info

Who referred you to this service?

Self-referralFamilyAgency

How did you find out about our service?

What is the name of the agency that referred you to our service?

Please enter the date you last worked (the final day of your most recent job)

Program Cohort

Preferred Phone

Preferred Email

Connect on social