Wellbeing Through Creativity
To be completed by the person attending or care coordinator. Please complete where possible ALL sections of the form. The form is confidential.
Name
*
First Name
Last Name
Email
*
example@example.com
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Why are you attending Wellbeing Through Creativity?
*
I'm available to attend
*
Thursdays 10 am - 12 pm
Date of birth
*
-
Month
-
Day
Year
Date
Address
*
Address line 1
Address Line 2
City
Borough
Postcode
Phone number
*
Contact permissions
*
Allow Email
OK to contact by phone
Fine with both contact methods
Emergency contact
*
Name of emergency contact
Relation to you
*
Emergency contact's phone number
Emergency contact's email
Gender
*
Female
Male
Non-binary
Transgender
Intersex
I prefer not to say
Ethnicity
*
Arab
Asian/Asian British: Bangladeshi
Asian/Asian British: Chinese
Asian/Asian British: Indian
Asian/Asian British: Other
Asian/Asian British: Pakistani
Black/Black British British: African
Black/Black British British: Caribbean
Black/Black British British: Other
Mixed: Other
Mixed: White and Asian
Mixed: White and Black Caribbean
Other Ethnic Group
White: British
White: Irish
White: Other
Prefer not to say
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Currently on benefits
*
Yes
No
If yes, please list (for example: Income support, disability allowance, incapacity benefit, etc.)
*
Put N/A if no
Have you been referred or self-referral
*
Being referred
Self-referral
If referred, who by:
Please give name of link/care worker or doctor (not care coordinator)
Care Coordinator's details
*
Care Coordinator's Name
*
Care Coordinator's phone
Care Coordinator's email
Clinical Diagnosis. Include any prescribed medication, side effects and your compliance with the treatment
*
Please give a brief description of current functioning and prognosis
*
Include drug and alcohol problems if present
Allergies
*
Please describe any physical health problems that may impact
*
Is there a forensic history?
*
Yes
No
If yes, please give brief details
*
Put N/A if no
Are the convictions spent
Yes
No
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How do you currently spend your time and are you motivated/ready to make vocational decisions?
*
Cultural issues
*
Including family role and expectations, finances, etc.
Is there anything else which it might be useful for us to know
*
Including employment history, training completed and qualifications gained
How long has it been since you were last employed if known
*
Years
Months
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Have you been referred to any other support services
*
Yes
No
If yes, please list
*
Put N/A if no
When was your first referral to a mental health service
*
Years
Months
Reason for referral
Include whether you are interested in full time, part-time, voluntary, paid work and/or studies/training
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How did you hear about Art4Space?
*
Do you give us consent to take photos?
*
Evidence for funding applications
For Social Media & marketing purpose
Signature
Date
-
Month
-
Day
Year
Date
Submit the form and let Gemma know that you have submitted it
This is a free course thanks to our funders, however we still have costs to cover and find. Are you willing to make a small contribution towards materials and refreshments, please do below.
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GBP
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