Self Referral Form
NetPark Wellbeing Art Course
We run a 12 week course at Metal Art School which incorporates walking in the park and using iPads and tradional art materials to create a reflective response. This course teaches new skills, helps to build self esteem and confidence.
Personal details –
Title (please circle) MS / MR / MRS / MISS OTHER
Name......
Address......
Contact telephone number......
Email......
Date of birth / /
Gender (please circle) M / F
Doctors contact details- ......
Are you currently under a mental health team? Y / N
If yes please give contact name and number -......
Have you used your GP or the crisis team in the last 12 months? If so how many times? (This question helps us with obtaining future funding for our project.)
......
Please state any third party organisation that may have referred you.
(SAVS, MIND, ect.)......
Please state any food allergies -
......
Please state any medical condition-
......
Please state any emotional difficulties- (anxiety, stress, ect)
......
Do you have any other condition that may require addition support?
......
What day and time is best for you to attend a NetPark course (please circle as many as appropriate)
MONDAY am/pm TUESDAY am/pm WEDNESDAY am/pm
Where did you hear about NetPark?
......
Ethnic origin (please circle)
White mixed or multiple groups
Asian, Asian British
African
Caribbean or Black
Other ethnic group
Not known
Declaration-
I declare that to the best of my knowledge the information have given is complete and correct
Netpark staff will not share my details with any other organisation
Netpark staff may use my personal information to contact me via post / email/ telephone.
The information you provide in this form will be kept confidential and will only be used by authorised staff. We will not share your data with anyone else except in a medical emergency. We may process data for statistical purposes.
Participants signature Date
...... / /
For further information about filling in this form please contact Emma Mills
Telephone – 01702470770 Email-
PLEASE RETURN BY POST OR EMAIL TO-
Emma Mills, Metal Art School, Chalkwell Park, Southend-on-Sea, SS08NB