Name
First Name
Last Name
Email
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How did you hear about Gifted Women?
Preferred contact method:
Phone call
Text
Email;
Right to Work in the UK
Is the woman legally allowed to work in the UK?
Eligibility
To be eligible for the Gifted Women Programme, you must have experience of at least one of these areas of Multiple Disadvantage (please tick all that apply)
Other barriers
We know that many women who have had these life experiences often also have experiences of one or more of the following, please tell us if you have experienced any of these:
Employment status
To be eligible for Gifted Women it must have been at least 6 months since you were last in employment or any formal education.
Employment goals
I understand that Gifted Women is about supporting me to take steps towards paid employment and this is something I am willing to do with help.
Learning disability and neurodivergence
Please tell us if you identify with any of the following, it does not need to be diagnosed: (tick all that apply)
How would you describe your ethnicity?
White.
Mixed or multiple ethnic groups.
Black, Black British, Caribbean or African.
Asian or Asian British.
Other ethnic group
Which best describes your sexual orientation?
Heterosexual/Straight
Homesexual or Gay/Lesbian
Bisexual
Other
Referrer Name
First Name
Last Name
Referrer Email
Referrer Phone Number
(###)
###
####
Organisation
Has the woman consented to this referral
Does Gifted Women have permission to contact the woman directly?
How would she prefer to be contacted? (e.g. text / email / phone cal)
