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Section 1. Details of Person Being Referred
Please enter the details of the person being referred in this section. If you are referring yourself for membership, please enter your own details and then click send at the bottom of the form. If you are a professional that is referring someone else for membership, please enter your details in section 2 before submitting the form. Once the form is submitted, a member of Trust Links staff will contact you to discuss joining our Growing Together Projects.
Title
Forename(s)
Surname*
Pronouns
Date of Birth
Gender
If other please state
Are you Transgender?
Which Growing Together Project are you interested in attending?
Please note: The Growing Together for Dementia his project is suitable for people with mild to moderate Dementia. Members of this project will need to be able to use the toilet independently as we cannot provide carers to assist with personal care. Those with personal care needs are welcome to attend with their own carer or family member.
Address line 1
Address line 2
Address line 3
Address line 4 (Town)
Address line 5 (County)
Postcode*
Accommodation Type
Main Telephone No.*
Mobile Telephone No.
Email Address (Main)
Emergency Number and Name
Tel Number of Keyworker
Job Role of Key Worker
GP Surgery
Please tell us about any gardening experience and other skills you have, for example customer service, IT/Computers, sales and construction (please include hobbies and interests)
Additional Disabilities
Do you feel that any of your disabilities could affect your work on the project? If yes, please briefly describe what you think these difficulties might be. This will help us know the best way to help you if you are having problems.
Do you have or have you had in the past, contact with the mental health team, social services, probation or any other service provider? If so, please give some details: when, who with, and for how long (approx)
Do you have a history of, or a current problem with alcohol or drugs?
What do you hope to achieve by becoming a member of Growing Together?
Do you have a carer?
Ethnic Group
Marital Status
Religious Group
Sexual Orientation
Dementia Diagnosis (Please state type)
Symptoms that would be useful for us to know about (i.e. hallucinations, agitation, word finding problems)
Are there any issues with mobility? (please describe)
Allocated Community Dementia Nurse Name
Other mental health diagnoses? (please state)
Any Physical Health Diagnoses? (please state)
Section 2: Details of referrer
Name of Referrer/Keyworker if you have one
Job Title (Referrer/Keyworker)
Organisation (Referrer/Keyworker)
Address
Telephone Number (Referrer/Keyworker)
Email Address (Referrer/Keyworker)