Ffurflen Gyfeirio - Referral Form

Thank you for your interest in accessing RCS support services. The In-Work Support Service provides rapid access to up to six free sessions of tailored physiotherapy, psychological therapy and occupational therapy services, designed to help employed, or self-employed people return to work or manage a health condition in work.

The In-Work Support Service also offers free support and training directly to businesses in the private and third sector, who often lack access to occupational health services.

Eligibility Criteria

Live in the North Wales, Carmarthenshire, Ceredigion, Pembrokeshire, Swansea or Neath Port Talbot;
Have a legal right to live and work in the United Kingdom; and
Are either employed or self-employed.

To help us identify what services are available in your area and assess your eligibility, please complete the below form.

You will be asked to provide identification to demonstrate you are eligible for this service upon receipt of your enquiry. As this service is funded by the Welsh Government, we are required to gather this securely to satisfy eligibility criteria.

RCS is committed to protecting your personal information; find out more about how in our Privacy Statement here. You can also find Welsh Government’s Privacy Notice here.

Our team will aim to get back to you within 5 working days to discuss your needs.

If you need to speak to us sooner, please contact us during our usual office hours for assistance.

WHO TO CALL IN A CRISIS

RCS is not an emergency mental health support service, and we cannot assist people who need more urgent and immediate support.

If you feel like you want to attempt suicide, if you have seriously harmed yourself (or about to), or need urgent medical assistance, please do not complete this form - you should call 999. Alternatively, you can contact:

The NHS for urgent mental health support by calling NHS Wales on 111 and pressing OPTION 2
The C.A.L.L. Helpline on 0800 132 737 or visit https://callhelpline.org.uk, for 24/7 mental health support

How did you hear about us?

If Other, please state where you heard about us:

Are you currently employed or self-employed?

Employed Self-employed

What do you need support with?

Is your health condition affecting your ability to do your job?

Yes No

Are you currently absent from work due to a physical or mental health condition?

Yes No

If yes, what was your first day of sickness absence?

Employment Sector

Preferred language for communications

Title

Forename

Surname

National Insurance number

Address Line 1

Address Line 2

Town/City

Postcode

Date of Birth

Home Phone Number

Mobile Phone Number

Can we leave messages?

Yes No

Alternative Phone Number

Email Address

Name of your employer, or business if self-employed (please note, we will not contact your employer without your consent):

Have you any requirements we need to be aware of? E.g., hearing loop, visually impaired etc

Please provide a brief description of the issues you are looking for support with, along with the best time of day for us to call you:

Would you like to be added to our mailing list?

Yes No