VISION Employment Support Services

Referring Your Client to Our Service

Vision 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 form here and send it in to us.

Referrer Information

Name of Referrer:

Telephone:

Agency:

Branch:

Referral Date:

Email Address:

Job Seeker Information

Surname:	Given Names:		Date of Birth:
Address:		Suburb:
Home Phone:		Mobile:
Email:
Next of Kin:	Relationship:		Phone:

Income Source

Invalids Benefit:

Sickness Benefit:

Unemployment:

Sole Parent:

ACC:

Non Beneficiary:

Disability Allowance:

Special Benefit:

Paid Employment:

Accommodation:

Other:

Please tick the boxes of services you are currently registered with:

Catapult

CCS

Creative Works

Workwise

Job Connect

Work Solutions

PATHS

Idea Services

Kaliedoscope

Lifelinks

Job Able / Skillwise

Enable Works

ACC

Workbridge

Hillmorton Hospital

Work & Income

The following information is required for us to help you find employment:

Work & Income Case Manager:

Phone:

Work & Income Work Broker:

Phone:

Work and Income Branch:

Work & Income Number:

Workbridge Consultant:

Phone:

IRD Number:

Tax Code:

Are you registered with Work and Income as looking for work?

Yes? No?

Please tick what type of disability(s) you have:

Physical:

Intellectual:

Sensory:

Physciatric:

Mental Health:

Medical:

Literacy:

Learning:

Neurological:

Autism/Aspergers:

Other:

What is your employment preference:

By submitting this form you are giving permission for this information to be provided to Vision Employment Support Services Charitable Trust as part of their referral process.