COAM Wellbeing Activities 2024 - Referrers' Registration Form

WELLBEING ACTIVITIES 2024

Referrers' Registration Form
Please complete as many sections of this form at possible and press 'Submit' at the end of the form. A member of the Museum's staff will contact you on receipt of this form to confirm arrangements, to discuss dates and transport options, and to answer any questions you may have.

Personal information will be treated with confidentiality and on a need-to-know basis. We will not forward personal details to any other organisation.

Thank you.
We are interested in (please select one or both):*

Accompanied WalksSummer Wellbeing Socials
REFFERER'S DETAILS:
Name

TitleFirst NameSurname
Relationship to participant/Job Title
Address
Postcode
Tel
Email
example@example.com
PERSON YOU ARE REFERRING:
Name

TitleFirst NameSurname
Address
Postcode
Tel
Email
example@example.com
D.O.B DD/MM/YYYY
GP Name
GP Surgery
Reason for referral
Please comment on the following if you think relevant or useful for us to know.
General mood, emotional difficulties
Communication, e.g. verbal, non verbal, uses an aid
Cognition, e.g. memory, processing, attention
Mobility, eg wheelchair or walking frame user and general motor co ordination
Any other relevant history / medical information, eg seizures, hearing, sight
Any food intolerances or allergies. If YES, please provide details.
Other information: Likes/dislikes, particular interests and skills
Please provide details for up to two other contacts or professionals involved in the Participant's care, e.g. carer, family member. One of these people (or you as the referrer) can accompany the Participant to the Museum.
Contact 1

TitleFirst NameSurname
Relationship to Participant/Job Title
Tel
Email
example@example.com
Will this person be accompanying the Participant at the Museum?

YesNo
Contact 2

TitleFirst NameSurname
Relationship to Participant/Job Title
Tel
Email
example@example.com
Will this person be accompanying the Participant at the Museum?

YesNo
I, the referrer, will be accompanying the Participant at the Museum?

YesNo
If you have the authority, do you consent to the named contacts being contacted by the Museum in case of an emergency?

YesNo
If you have the authority, do you consent to the named referral to be included in recording/filming/photography for training purposes/presentations/funding applications/ project reports/ publicity?

YesNo
I confirm that the patient has given consent for me to share their contact details with Chiltern Open Air Museum for the purposes of Accompanied Walks.

YesNo
Referrer's Name
Signed

Clear
Date

MonthDayYear
Date
Should be Empty:

WELLBEING ACTIVITIES 2024

REFFERER'S DETAILS:

PERSON YOU ARE REFERRING: