Referral Form

Please Note: This form is only required for professional services referring a participant to our programmes - if you want to refer yourself to our programmes, please use our Contact Us page.

1. Referral Source & Consent

Referral Type
GP/NHS Health ProfessionalHGA Hub/Social PrescriberCommunity OrganisationOther
Referrer Name

Organisation

Contact Phone

Contact Email

2. Person's Details

Name

Address



Town

Postcode

Date of Birth (required)

Gender
MaleFemaleNon-binaryPrefer not to say
Home Phone

Mobile Phone

Email

Preferred Contact Method
Home PhoneMobile PhoneEmail
Can we leave a voicemail if you do not answer?
Is there a good time to contact?

3. Programme/Service Selection

HGA ProgrammeMen's Only GroupSEND WorkshopsQuilting Retreats/Creative TextilesOther (please specify in additional details)
If other, please specify:

4. Eligibility Criteria

Mild to moderate mental health conditionChronic Pain/MSK IssueNeurodiversity (e.g. ADHD, ASD)Risk of leaving work or educationDigital Exclusion/Low Digital ConfidenceSocial IsolationOther (please specify in Additional Details)
If other, please specify:

5. Referral

Reason for referral:

How might Sew Mindful Crafts help (outcomes/support sought)?:

Does the person currently have other support?:
YesNo
If yes, please outline who and how often:

6. Additional information

Health conditions, accessibility requirements, transport issues, preferred session times etc.

7. Data & Consent

(Required) I confirm that consent has been obtained from the person named in Section 2 for this referral
(Required) I consent to Sew Mindful Crafts CIC storing and using this information under its Safeguarding Policy and Privacy Notice
(Optional) Keep me posted about news, events and future opportunities