Digital Skills Training Referral Form - Tameside

Referrer information

Referral organisation *

AgeUK
Big Local Ridge Hill
Garside Kidd Centre
Jigsaw Homes (please state which team below)
Other organisation

Which Jigsaw Homes team? *

Organisation name *

Date of referral *

Referrer name *

Referrer Pronouns

Referrer email *

Referrer phone number *

Job title/Relationship to Client *

Client information

Client name *

First

Last

Client title

e.g. Mrs, Ms, Mr, Dr, Rev.etc

Client pronouns

Client prefers to be called

Client phone number

Client email

Client Date of Birth *

Client Address

Address Line 1

City

State / Province / Region

Postal Code

Ethnicity *

Rearranging one-to-one sessions *

The client understands that they MUST contact their digital tutor/champion if they are not able to attend a one-to-one session.

Please note: Some of our training venues have IT suites available. Or, attendees can bring their own equipment, or a portable device might be provided for use during the session, if available, on request and by arrangement only.

At Digital Training Groups one-to-one support will be available as far as possible, but clients must be aware they may not have someone working with them for the whole session.

We receive some of our funding to support people facing particular life issues. Please indicate which life issues the project can address through providing digital support:

Does lack of digital access make it difficult for the Client to get help with any of these situations? *

Nowhere to live
Might lose their home
Can’t find work
Not enough money
Struggling with debt
Not enough food
Struggling to get benefits
Victim of a crime
Accused of a crime
Other legal issues
Mental health issues
Domestic abuse
Health condition
Alcohol addiction
Addiction to other substance
Disability
Childcare
Is a Carer
Is a Support Worker
Other - please explain below

Why does the Client want to undertake Digital Skills training? *

Improved general wellbeing
Improved employment prospects/job searching
Increased education opportunities
Enjoyment of a hobby
Engagement with community
Better management of health conditions
Reduced isolation/Keeping in touch with family/friends
Ability to better support a child
Attendance of a support/social group
Ability to shop online
Financial/household management
Better able to support clients
Other

Tick as many as apply

Please provide any further details about the client's Digital Skills training needs

Does the Client already have any of this equipment to use while training?

Mobile phone (non-smart)
Smart phone
Tablet
Laptop
Desktop

Equipment details - if known

Details of equipment such as age and operating system(s)

Does the Client need to borrow equipment (if available) whilst attending a Digital Training Group?

Tablet (Android)
Laptop - Windows or Chromebook

Are there any known risks or safeguarding issues regarding this Client? *

Any other relevant information

e.g. language barriers, mobility issues, sight/hearing impairment, etc.

Information cannot be changed beyond this point

Proceed to declaration and SUBMIT

GDPR Agreement and declaration *

I, the Referrer, consent to this website sending the submitted information to PCrefurb. The Client has given permission for their details to be given to PCrefurb.