Manor & Castle Development Trust VCSE/SHSC Waiting List Project Referral Form

VCSE/SHSC Waiting List Referral Form

This form enables you to apply to gain support from Manor & Castle Development Trust's mental health support and other community projects in 2022.
Referrer Details
Referred by:
Contact Number
Please enter a valid phone number.Format: 00000000000.
Contact email
example@example.com
Client Details
Client ID (Office Use Only)
Client Name
GP Surgery
Date of Birth

DayMonthYear
Date
Ethnicity
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Landline
Please enter a valid phone number.Format: 0000 0000000.
Mobile Phone
Please enter a valid phone number.Format: 00000000000.
Contact email
example@example.com
What is the reason for referral?
Woodland Confidence CoursesTake Part in the gardenTake Part On line self care groupTake Part in the sewing RoomGet Creative Drama & music (pending)Forget-Me-Nots singing groupArts & CraftsMen's Social Group.Physical Activity sessions including Health Walks ,Zumba, Boxercise, Women's Football and more
NoneImpaired MemoryHearing IssuesMental ill healthDevelopmentVisualLearningCommunicationMobility or physicalPrefer not to sayOther
EmailPhoneTextLetter
When referring the client to MCDT, please make sure you have made them aware of the following consent statements and that they agree:
- I give Manor & Castle Development Trust Ltd(MCDT) consent to hold my information safely and securely (Paper or digital-based) for providing their services to me.
- I understand that MCDT may from time to time share my information with partner organisations only. To enable them to provide additional services to me if they cannot provide everything I need.
- I understand my information will be retained by MCDT for 6 years after I have finished receiving services. Where it will then be properly and securely destroyed.
- I understand I have the right to see at any time what information MCDT holds on me and I know that I can withdraw my consent at any time.
- I can request this information from MCDT at any time by contacting the MCDT office on 0114 2789999. Has the client agreed to the above statements?
YesNo
Should be Empty:

VCSE/SHSC Waiting List Referral Form

Referrer Details

Client Details