Referral Form WCO project

Referral Form - Working Care Out Programme
The Working Care Out Project supports family carers aged 18 to 65 years who want to go back to work or education. A family carer is someone who spends time caring for a family member, relative or friend in an unpaid capacity. We work with the family carer to think about their caring role, wellbeing and any questions and worries they may have about returning to work or study. We offer a range of supports including a one-to-one wellbeing review, access to a drop-in clinic and a virtual support group and skill development programme. Family carers can avail of as much or as little support as they need and this programme is FREE OF CHARGE!
About The Family Carer
Name:

First Name Last Name
Date of Birth:

Day Month Year
Address:

Street Address

Street Address Line 2

City City/County

Eircode
Mobile Number:
Landline:
Email Address:
example@example.com
Reason For Referral - (Please tick all that apply)
Requires one-to-one wellbeing assessment action plan, to enhance wellbeing as a family carer with a focus on self-esteem and confidence building Requires support to identify potential opportunities and barriers and how to work around these areas to engage in employment/education Requires information and advice on rights and entitlements to return to the workforce/ education. Requires one-to-one/group training / workshops to identify how to plan and organise the caring role to enhance opportunities to return to work / educatio Requires training in interview preparation, communication and technology skills. Requires support to identify and sustain care/ work/ education routine. Other – please specify
If Other (please specify
Office Use Only Date Referral Received:

Should be Empty:

Referral Form - Working Care Out Programme

About The Family Carer

Reason For Referral - (Please tick all that apply)

Name of Person Making the Referral:

Organisation Name:

Consent: