Referral Form

Participant Projects & Activities

Can participant travel independently?(Required)

Yes

No

Area Participant can attend(Required)

Choose any that apply

Blaenau Gwent

Please specify what project or activity you wish to refer in for. Each choice is defined by a location of your chosen area. You only need to choose one.

Terence Gardens

Horticulture

Music

Café - Volunteering & Employability

Arts and Crafts

Brynithel

Woodwork

Caerphilly

Please specify what project or activity you wish to refer in for. Each choice is defined by a location of your chosen area. You only need to choose one.

Tŷ Siriol

Horticulture

Music

Art & Craft

Hafod Deg

Woodwork

Horticulture

Blackwood Shop

Volunteering

Employability

Art & Craft

Gwent

Please specify what project or activity you wish to refer in for. Each choice is defined by a location of your chosen area. You only need to choose one.

Gwent Wide

No More Barriers employment project: Supporting those with mental health, autism and learning disabilities.

Accredited & non-accredited training

Volunteering

Employability

Peer Mentor Training

Monmouthshire

Please specify what project or activity you wish to refer in for. Each choice is defined by a location of your chosen area. You only need to choose one.

Mardy Park

Horticulture

Music

Art & Craft

Tree Nursery

Horticulture

Newport

Please specify what project or activity you wish to refer in for. Each choice is defined by a location of your chosen area. You only need to choose one.

Tredegar House

Horticulture

Music

Art & Craft

Tredegar House Shop

Volunteering & Employability

Torfaen

Please specify what project or activity you wish to refer in for. Each choice is defined by a location of your chosen area. You only need to choose one.

Nant Bran

Horticulture

Music

Art & Craft

Catering - Volunteering & Employability

Talygarn Allotment

Horticulture

Cardiff & The Vale

Please specify what project or activity you wish to refer in for. Each choice is defined by a location of your chosen area. You only need to choose one.

Cardiff & The Vale

Peer Mentor Training

Accredited & non-accredited training

Employability

Participant Information

Participant Name(Required)

First Last

Participant Address(Required)

Street Address Address Line 2 City County Post Code Country

Participant Telephone Number(Required)

Participant Date Of Birth(Required)

National Insurance Number(Required)

National Insurance Number. An NI number is made up of two letters, six numbers and a final letter.

Are they claiming benefits?(Required)

Yes

No

GP's Name(Required)

GPs Address(Required)

Doctors Surgery & Street Address Address Line 2 City County Post Code Country

Participant Questions

Please specify client’s mental health and/or learning disability and the support required from this service(Required)

If not applicable please add N/A.

Details of medication, and any side-effects resulting from medication(Required)

If not applicable please add N/A.

Are there any risks to be aware of?(Required)

Yes

No

Please list the risks and details(Required)

Details of any counselling, psychiatric therapy, or other mental health intervention(Required)

If not applicable please add N/A.

Has the participant ever misused drugs or alcohol?(Required)

Yes

No

Please give details on drugs or alcohol(Required)

Social History(Required)

Include social background and brief history. Current home circumstances, past occupations and interests, current medical condition.

Emergency Contact Name(Required)

First Last

Emergency Contact Telephone Number(Required)

Emergency Contact Address(Required)

Street Address Address Line 2 City County Post Code Country

Confirmation

Referrer Name(Required)

First Last

Referrer Email(Required)

Referrer Telephone Number(Required)

Hey there, please remember to keep an eye on your junk folder throughout the process. If you’re expecting something from us, chances are we have already sent it.

Hidden

Referrer Organisation, Team and Borough

(e.g. CMHT – North Caerphilly)

Referrer Organisation, Team and Borough(Required)

Other - Referrer Organisation, Team and Borough(Required)

(e.g. CMHT – North Caerphilly)

Referrer Address(Required)

Street Address Address Line 2 City County Post Code Country

Name of current Care Co-ordinator(Required)

First Last

Telephone Number of current Care Co-ordinator(Required)

Email of current Care Co-ordinator(Required)

Referrer Signature(Required)

Date

Comments

This field is for validation purposes and should be left unchanged.

Online Referral Form

Participant Projects & Activities

Blaenau Gwent

Caerphilly

Gwent

Monmouthshire

Newport

Torfaen

Cardiff & The Vale

Participant Information

Participant Questions

Confirmation

Links

Address

Charity Information

Contact Details

Download Referral Form