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. Please note that the sessions are full at the moment, but please fill out the form so we can be in touch when we have available spaces.
Name
*
First Name
Last Name
Email
*
example@example.com
Your email will be added to the monthly wellbeing newsletter from Art4Space unless you opt out below.
Opt out
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
Back
Next
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
Back
Next
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
Back
Next
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
Back
Next
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.
prev
next
( X )
GBP
We have set this at £10, however if you can donate more or less
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
Submit
Should be Empty: