Wellbeing Exeter Self-Referral Form

Wellbeing Exeter and Cranbrook Self Referral Form

Please note that Exeter only takes referrals for adults aged 18+ only. Cranbrook takes referrals for adults, families and young people aged 11-17.
Name (if this is a referral for a family in Cranbrook, please put details of parent, NOT the child):*

First NameLast Name
Preferred Name (if different from above):

First NameLast Name
Date of Birth:*

DayMonthYear
Gender:*
Preferred Pronouns:
Address:*

Address Line 1

Address Line 2

CityCounty

Postcode
Preferred Phone Number:*

Area CodePhone Number
Email:
Contact Preferences (tick all that apply):*

PhoneVoicemailTextWhatsAppEmailLetter
Young Person Referral Only (Cranbrook)

Please fill in this section if this referral is for a Young Person (aged 11-17) in Cranbrook - if not, then move on to the next section.
School / College Attended:
If the young person is aged 11-13, we require their parent / carer's contact details here:
Parent / Carer's Name:

First NameLast Name
Parent / Carer's Relationship:
Parent / Carer's Phone Number:

Area CodePhone Number
Parent / Carer's Email:
example@example.com
Consent

We need your consent in order to work with you.
I consent to be contacted and for my details to be held by Wellbeing Exeter & Cranbrook.*

Yes - please proceed with referral (we cannot work with you without this consent)
Working with Wellbeing Exeter & Cranbrook
What do you hope to gain through Wellbeing Exeter (tick as many as apply):

Discover opportunities on how to live and feel betterImprove wellbeingInformation about available resources and opportunitiesIntroduction to groups (social, support, activity etc)Support to access education / training / learn new skillsSupport to meet new people / get to know the community betterThe chance to talk to someone and be listened toOther
If you selected "Other" above, please add details here:
What do you need support with?*

SocialEmotionalPracticalPhysical Health / DisabilityPhysical Activity
Eligibility Criteria
Please acknowledge you meet the eligibility criteria to proceed:*

Live in Exeter or CranbrookNot already registered with Wellbeing Exeter & CranbrookReady to engage with a Community Connector
Disclaimer: Wellbeing Exeter & Cranbrook reserves the right to limit, suspend or refuse services to anyone based on our professional opinion, and at our discretion at any time, and without giving details or reasons.
Should be Empty:

Wellbeing Exeter and Cranbrook Self Referral Form

Young Person Referral Only (Cranbrook)

Consent

Working with Wellbeing Exeter & Cranbrook

Eligibility Criteria