Referral form

Ecotherapy referral form

Are you completing this form for yourself or on behalf of someone else?*

Main Referrer/Contact

If other - please state referrer organisation or relationship to participant

Referrer details (i.e. name, job role/relationship, phone number, email address)*

How did you hear about us?*

If other, please state

Participant's details

Surname*

First Name*

Preferred Name

Date of Birth*

Address line 1*

Address line 2

Address line 3

Town*

Postcode*

Landline Telephone No.

Mobile Telephone No.

Primary Email Address

Preferred Method of Communication: Please state either Telephone, Text or Email*

Gender*

If other, self-describe

Preferred Pronouns*

If other, self-description

Participant's emergency contact information: Who can we call in an emergency?Please provide contact details - including name, relationship and contact phone number*

GP Surgery*

If other - please state details

Please complete the below section with the participant's details

Do you have a disability / long term health condition?*

Do you have a mental ill-health condition?*

Are you neurodiverse?*

If you have selected yes to any of the above please provide additional details:

Do you have any social and/or communication needs? If so, please provide details

Please provide details of any known risk / safeguarding considerations relating to the participant that St Nicks should be aware of.If none, please leave blank.

What main difference do you hope ecotherapy will make for you?

Mental Wellbeing

Physical Wellbeing

Connect with Nature

Learn new skills

Increase social connections

Other

Other reason

What kinds of activities would you (if filling in for yourself) or the participant (if filling for someone else) like to join?

Getting active

Gardening

Wildlife conservations

Writing/Poetry

Bushcraft

Getting creative

By submitting this form you consent to the information provided being securely stored by St Nicks in line with our Data Protection Policy and in compliance with the General Data Protection Regulations outlined in our Privacy Policy, which you can find on the Ecotherapy webpage: https://www.stnicks.org.uk/nature-based-wellbeing/ecotherapy/forms/