THRIVE self-referral form

Inspired by Art at The Bureau self-referral form

Please register your interest and we will get back in touch.
Name*

First NameLast Name
Contact Email
example@example.com
Postcode*

Street Address

Street Address Line 2

CityState / Province
Contact phone number*
How did you hear about us? *
Are you OK to attend in person within a group? Please tick a box.*

YESNO
What do you hope to gain by attending a group? *
THRIVE is a creative and wellbeing project offering a number of activities. Please tick those you are interested in and we will try and match you with suitable groups.*

Artist-led groupChair YogaPlace of Welcome meet upRelaxed art and chatArt and MindfulnessParent and Child Art GroupDrumming GroupOnline sessionsMusic GroupCraft GroupPhotographyNature & OutdoorsOther
Which days of the week are you able to attend?*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Have you attended any other groups before, either at The Bureau or in other places?
MENTAL HEALTH: Do you wish to tell us about any mental health conditions you may be experiencing? *
PHYSICAL HEALTH: Do you wish to tell us about any physical health conditions you may be experiencing? *
Do you need special assistance during session to help with any Physical or Mental condition? (e.g. wheelchair access, support worker present etc.)*
Is there anything else you would like to tell us about, including any hobbies or interests?
Are you currently in any paid work, including zero hours contracts, or have you volunteered before?
Your age range*

Under 1616 - 2425 - 4950 - 5960 -6970 -7980 -8990 +Other
Ethnic Group

WhiteMixed / Multiple Ethnic GroupAsian / Asian BritishBlack / Black BritishOther Ethnic GroupPrefer Not To Say
We would love to keep you updated with our email newsletter. Would you like to sign up to receive it?*

YESNO
If somebody completed this form for you, please add their name here.
Please leave blank if required.
The THRIVE creative community and wellbeing project is a nationally funded project in the heart of Blackburn and Darwen.

Someone will be in touch with you soon.

For more information please contact james@bureaublackburn.co.uk or cath@bureaublackburn.co.uk

Please be aware that this information will be stored securely and retained at least until 31st December 2026, in compliance with the Data Protection Act 2018.
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Inspired by Art at The Bureau self-referral form