Self Referral Form for Thrive 6-week Education Mentoring Programme

Client Contact Record

First Name(Required)

Surname(Required)

Date of Birth

Mobile Number

Prison Number (if applicable)

Email Address (if applicable)(Required)

Address Line 1

Address Line 2

Town / City

County

Postcode

Do you have support needs? YES or NO(Required)

YES

If yes, please provide details:

For us to support you effectively throughout the Thrive Community project, we need to register you on the programme. This is a career development programme supporting you in exploring career opportunities and addressing health inequalities. We work with you to assist you in exploring career opportunities and we can connect you with a wide range of services who can also support you if required. For us to support you we need to gather, hold and sometime share your information.

Do you give explicit consent for us to collect your information, YES or NO?(Required)

YES

Do you give consent for us to share this information with a range of agencies including – Police/Probation/Prison/ NHS/ Courts/Education, training providers, VCSEs and other services as required who will support you? The information will be shared to support awareness of your engagement on the programme and your activity seeking employability and career opportunities.(Required)

YES

Nature of Offence

Are you subject to orders/restrictions accessing digital content?