Tale Be Told Youth Theatre Registration Form

Access Support - The Wellness Canvas

Free creative arts course to support your mental health& wellbeing
Participant's Name:*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Mobile Number:*
Email:*
example@example.com
Post Code:*
Ethnicity:*
Are you under mental health services?*
Do you have any additional needs or medical conditions that we should be aware of?*
Do you have any allergies?*
How did you hear about this programme? (Mental Health services, GP, Social prescribers, social media, organisation, self-referral etc)*
Emergency Contact

Who can we contact in an emergency?
Name*

First NameLast Name
Relationship to you*
Contact's Mobile Number*
IMPORTANT INFORMATION ABOUT BOUNDARIES - read before taking part in our sessions:

We all need boundaries. Boundaries keep us safe. Boundaries differentiate me from you. Boundaries help us focus on what is most important to us and boundaries improve relationships by creating clear expectations and responsibilities. Below are some boundaries we ask all of our participants to follow in our sessions:
- Attendance: The Wellness Canvas is a 10 session course and we ask you to attend all 10 sessions to receive the full benefits of the programme.
- Being in a group: group dynamics are vital to our work and it is important to remember that you are a part of a group, a piece of a bigger puzzle.
- Respect personal boundaries of other participants and staff, this may include proximity, touch or topics talked about etc.
- Be mindful of your tone, language and body language.
- Sharing: only share what you are comfortable with.
- Abilities: people may have different abilities to yourself and don’t just assume they can do everything you can do.
- Fairness & equality: you may not discriminate against people (staff and participants) on the grounds of:
- sex and gender,
- gender reassignment,
- sexual orientation,
- disability,
- race,
- religion & belief,
- age etc.
- Discrimination will lead to individual(s) being excluded from the programme.
- Timing: arrive on time, please notify staff if you are going to be late or absent.
- Wear appropriate and comfortable clothing.
- Talk to staff: If you feel uncomfortable or unhappy about your experiences within the group.
- Have an open mind and give all activities a try. Most importantly have fun & connect with others around you.
When boundaries are broken

If boundaries are crossed or blurred it can be unsettling for the group and can lead to the space feeling unsafe. If this happens, we will take immediate action:
1. Stage 1: a talk will be held between individual(s) and staff to discuss the issue and create clear steps to rectify it.
2. Stage 2: if boundaries continue to be broken an official warning will be issued.
3. Stage 3: if boundaries continue to be broken after stage 2, the individual(s) will be excluded from the programme going forward.
If you have any questions please do talk to staff, we are here to support you.
Health Care Questionnaires

These programmes are designed to support your mental health and wellbeing. We do a pre-project survey, mid-project survey and end-project survey to see the impact of the programme.

Patient Health Questionnaire (PHQ-2). Over the last two weeks, how often have you been bothered by the following problems?*

	Not at all	Several days	More than half the days	Nearly every day
Little interest or pleasure in doing things?
Feeling down, depressed or hopeless?

General Anxiety Disorder 2 (GAD-2). Over the last two weeks, how often have you been bothered by the following problems?*

	Not at all	Several days	More than half the days	Nearly every day
Feeling nervous, anxious or on edge?
Not being able to stop or control worrying

Acknowledgment
*Tale Be Told Theatre C.I.C is the data controller for this project. All data received is subject to a duty of confidentiality. Statistical date will be shared where appropriate with the NHS, this is not considered personal data as you cannot be identified by it. This sharing of data allows for the evaluation of our services and the impact of it. All data will be appropriately deleted once the programme is complete.

Contact Kulraj on kulraj@talebetold.co.uk or 07497 853323 If you have any questions.

I have answered all of the questions correctly and I understand the clear boundaries set out in this document.
Signature

Clear
Date Signed

DayMonthYear
Date
Thank you for taking the time to fill out this document and we look forward to having you joining our programme.
© Tale Be Told Theatre C.I.C.

Tale Be Told Theatre is a Community Interest Company, Registered in England, limited by guarantee. Company Number: 10439178
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Access Support - The Wellness Canvas

Emergency Contact

Health Care Questionnaires

Acknowledgment