Our WorkPlace External or Self-Referral Form

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Please complete the form with as much information as possible. It really helps us going forward into an assessment with the client/community member.
Should you have any questions - feel free to contact us at 778-817-0354 ext. 3004 or ourworkplace@ourplacesociety.com

Name of person interested (or referrer) in Our WorkPlace services *

How can we get in touch with you? Please provide the contact phone number or email of interested person or referrer. *

What program are they/you interested in? (if known) *

People in Progress

Digital Job Seekers

Our WorkPlace employment support

Required

What agency do you work with? (if applicable) *

Barriers to Employment: *

Mental Health

Physical Health

Substance Abuse

Homelessness

Lack of life skills

Transportation

Criminal Record

Lack of Computer Skills

Other:

History of violence or aggression *

Yes

Required

Why do you (or the person you are referring) believe you are ready to commit to employment? *

Why do you (or the person you are referring) believe you are ready to commit to the twelve-week People in Progress program? *

Please describe in as much detail as possible how you (or the person you are referring) demonstrates the following attributes: Shows Initiative; Takes Personal Responsibility; Teamwork (getting along with others) *

Are there any additional supports that would help facilitate participation in workshops and/or employment (ie: bus tickets, disability assessment, literacy supports, access issues) *

Any other details you think we should know *

For this referral to be processed it must be approved by your Team Lead or Supervisor. Please have them sign or type their name on the line below. *

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