Connect to Work Suffolk – Professional Referral Form

Please fill in the form below ensuring that all the “Required” boxes are complete. This information is needed for us to assess your eligibility for the programme.

Section 1 – Eligibility and background

Section 2 – About the referrer

If Yes, which PCN area(s) do you work in (select all that apply):(Required)

Referring organisation:(Required)

Referrer's telephone number:(Required)

Referrer's email:(Required)

Section 3 – About the participant being referred

Participant's date of birth:(Required)

Participant's national insurance number (if known):

Participant's telephone number:(Required)

Participant's gender(Required)

Please select the participant's local GP surgery/clinic (start typing or select from the list below):

If your surgery does not appear in the list above, please type it in the box below:

This field is hidden when viewing the form

Client source

Statement to read by the Referrer to the Participant being referred

Your Personal Data

Seetec is committed to data security and the lawful, fair and transparent processing of personal data. We will process the personal data you provide only for the purposes of joining the Connect to Work Suffolk Programme and to provide the referrer with updates on your progress.

Your data will be retained only for as long as necessary to complete this process, and if you decide that you no longer wish to join the programme or your referral is not approved, your data will be deleted from our systems within 30 days of notification.

We may retain anonymised data (data which cannot be associated with you) for statistical and reporting purposes.

For further information on how Seetec processes personal data, please see our privacy policy.

By making this referral the referrer confirms that they have explained the purposes for the data sharing by reading the above statement to the Participant being referred and that the Participant has given their consent for data to be shared between Seetec Pluss and the Referrer for the purposes of joining and progressing on the Connect to Work Suffolk Programme.

CAPTCHA

Connect to Work Suffolk – Professional Referral Form

Section 1 – Eligibility and background

Section 2 – About the referrer

Section 3 – About the participant being referred

Is Connect to Work right for my referal?

Quick links

Legal

Already on one of our programmes?

Already on one of our programmes?