Client Details Please tick the programmes you are interested in: * The Way Forward Steps2Success At Your Service Title * Please Select Miss Mrs Mr Ms Other First name * Surname * Date of birth * Day Month Year Phone * Email * Ethnicity * Please Select White British White Irish White Any Other Background Mixed White and Black Caribbean Missed White and Asian Mixed Any Other Mixed Background Asian Indian Asian Pakistani Asian Bangladeshi Asian Any Other Asian Background Black Caribbean Black African Black Any Other Black Background Chinese Any Other Ethnic Group Not Stated Gender * Male Female Address line 1 * Address line 2 Town/City * Postcode * Are you a BCHA Resident or Tenant? * Yes No Where/How did you find out about us? Please Select Social News TV Jobcentre Word of mouth Other Please explain in detail * Employment Are you currently in receipt of Universal Credit? * Yes No Are you currently working? * Yes No Last month/year of employment? * Month Year Are you currently receiving any training? (apprentice/traineeship)? * Yes No Are you currently in education? * Yes No Do you have Proof of Right to Work in the UK? * Yes No Emergency Contact Emergency Name * Emergency Number * Relationship * Referral Service Details (if applicable) Referrer name Referrer phone Important Client Information Do you consider yourself to have a disability or any other health issues? * Yes No Please give details below * Are there any barriers to work that we should be aware of? * Yes No Please give details below * Please ensure this form is fully completed and signed as we are unable to proceed without this information. Once received, we will be in contact with you. * By signing this document, I have read and agree with BCHA’s Privacy Notice and give consent for BCHA to share any of the above information with third parties if a risk is disclosed. Was this information helpful?
