Art For All Application Form

1

Name* This field is required.

First Name

Last Name

2

Date of ApplicationWhat is today's date?

Date

3

Thank you for taking the time to fill out this form. Please answer the questions as honestly as possible so we can assess whether Art for All is right for you. Art for All are art classes for those currently suffering from or are in recovery from, any mental health condition, any mild learning difficulties or physical disabilitys, neurodiversities and anything that causes loneliness and social isolation. All information given is confidential.

4

Date of Birth

Date

5

Email

example@example.com

6

Contact Telephone Number

Please enter a valid phone number.

7

Preferred Method of Contact

Text

Phone Call

Email

9

Next of Kin

First Name

Last Name

10

Next of Kin Phone Number

Please enter a valid phone number.

11

Next of Kin Email

example@example.com

12

Do you have someone who you give us permission to contact if you become unwell or the facilitator have any concerns about you during the class? If so, what are their contact details?i.e. care coordinator, CPN

13

Current mental or physical health diagnosis? (e.g. anxiety, stress, ASC, mobility issues)

14

Tell us a bit about your mental health history(optional)

15

Have there been any episodes of violence/anger/challenging behaviour in the past?

16

Any other health issues we need to be aware of?(e.g. mobility issues, epilepsy etc)

17

Any additional information you would like us to know?

18

Would you need to bring a support worker with you when attending an Art for All class?

19

Where did you hear about Art for All?