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 & ConsentReferral TypeGP/NHS Health ProfessionalHGA Hub/Social PrescriberCommunity OrganisationOtherReferrer NameOrganisationContact PhoneContact EmailNext2. Person's DetailsNameAddressTownPostcodeDate of Birth (required)GenderMaleFemaleNon-binaryPrefer not to sayHome PhoneMobile PhoneEmailPreferred Contact MethodHome PhoneMobile PhoneEmailCan we leave a voicemail if you do not answer?Is there a good time to contact?BackNext3. Programme/Service SelectionHGA ProgrammeMen's Only GroupSEND WorkshopsQuilting Retreats/Creative TextilesOther (please specify in additional details)If other, please specify:BackNext4. Eligibility CriteriaMild 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:BackNext5. ReferralReason for referral:How might Sew Mindful Crafts help (outcomes/support sought)?:Does the person currently have other support?:YesNoIf yes, please outline who and how often:BackNext6. Additional informationHealth conditions, accessibility requirements, transport issues, preferred session times etc.BackNext7. 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 opportunitiesBack
