Self Referral Form NETPARK

Connect & Create Self Referral Form

Metal's Community Wellbeing Programme
We run a 10 week groups at Metal Art School which incorporates walking in the park, using technology and traditional art materials to create a reflective response.

We also offer dementia art groups and a trauma psychoeducation class. Our groups are for adults 18+.

These groups encourage new skills, aim to reduce social isolation, improve confidence and help to build self esteem.
Name
Address
Contact telephone number

+44Phone Number
Email
example@example.com
Date of Birth (DD/MM/YY)
Gender Identity
Emergency Contact Name
Emergency Contact Number
Registered GP Surgery
Are you currently under a NHS mental health team?

YesNoPrefer not to say
If yes, please provide a contact name and number
Have you used NHS services (GP, mental health services, crisis team) in the last 12 months to help you manage your mental health?

YesNoPrefer not to say
If yes, how many times have you seen any of the above in the last 12 months. This question helps us with obtaining future funding for our project.
Did receive a referral from SAVS, Social Prescriber or your GP etc?
Do you have any food allergies?
Do you have medical conditions our facilitators should be aware of?
Do you consider yourself to be neurodivergent?

YesNoPrefer not to say
Please share any emotional difficulties you are currently experiencing? Such as anxiety, depression, stress etc.
Do you have any access needs?
What do you like to achieve by joining a Wellbeing @ Metal group?
Which day / time best suits your availability?

Monday AMMonday PMTuesday AMTuesday PMWednesday AMWednesday PM
What is your ethnicity?

Asian or Asian BritishBlack, Black British, Caribbean or AfircanMixed or Multiple ethnic groupsWhiteOther
Workshop Photography Consent
This form is a record of your approval for us to document your participation through photography and filmography. The material recorded through the workshop sessions will be utilised in media, print, online and film. Please note Metal is a registered charity and all media generated will be for non-commercial use.

By signing this form, you give your agreement for your participation and voluntary contribution to the project, please read carefully the information below and fill your information in the required fields. Please fill out two (2) copies of this form, one for your own records and one for Metal.
Where did you hear about Wellbeing @ Metal?
I declare that to the best of my knowledge the information I have given is complete and correct.

Information provided in this form will be kept confidential and in compliance with GDPR regulations.

Programme facilitators may use my personal information to contact me via post / email / telephone.

We will not share your data with anyone else except in a medical emergency. We may process data for statistical purposes.
Participants signature

Clear
Date

MonthDayYear
Date
If you have any questions and/or comments about privacy, please email us at edgehill@metalculture.com, call 0151 7072277, or speak to a member of staff.

For further information about the programme / this form please contact Emma Mills or lan Wilson on emma.mills@metalculture.com or ian.wilson@metalculture.com

Metal Art School, Chalkwell Park, Westcliff-on-sea, SSO
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Connect & Create Self Referral Form