Referral Form - Glossop Arts Project

To refer yourelf or someone else to one of our groups or activities, please fill in the form below –

Our sessions are Arts for Wellbeing which aim to support people with their mental health and wellbeing. Please state briefly what the mental health or wellbeing needs are e.g. anxiety

Please select which of our activities you're referring for (required)

Please select an activity you're referring for

Arts for Wellbeing

The information you give us will be used for statistical (anonymised) evaluation purposes, to enable us to contact you and/or the participant if circumstances mean there are changes to session dates or times etc and, if you agree, to contact you about future events we think might be of interest to you. It will also help us consider any specific requirements you or the participant may have.

Arts from Home

Art packs will be hand delivered fortnightly by one of our Art leads at GAP. We hope that by meeting us at home, chatting and enjoying the activities in the pack, that the participant could feel able to attend regular sessions in the future.

We understand every person is different and once we receive the referral, we will work directly with the participant to best meet their needs.

Participants Profile

Name (required)

Date of Birth (required)

Address (required)

Please enter an address

Telephone number (required) Email address (required)

Preferred way to contact (required) PhoneEmailPost

Emergency Contact

Name and contact number of someone we could call for the participant in case of emergency

Name (required) Contact telephone number (required)

Their relationship to you (required)

Helping Us to Help You

Do you consider the participant to have a disability/long term health condition or to feel socially isolated? YesNo Please give brief details:

Please briefly outline the reason for requiring an Arts from Home pack rather than attending a face to face session.

Is there anything we need to be aware of to help us deliver enjoyable and suitable sessions and/or resources for the participant (e.g. fears, phobias, physical limitations, etc)?

This section only need to be completed if you're referring someone else.

Referral made by

Name of referrer if you are referring someone else

Organisation name

Email address Telephone number

Has the person agreed to you making this referral? YesNo

And lastly...

How did you hear about GAP?

Protection of your information

Only staff at Glossop Arts Project will have access to your information. It will be kept securely and not shared with any other individual or organisation without your permission. Any project reports will use anonymised data only unless you give your permission for a case study.

Your information will be held only for as long as is necessary for funding or session requirements. It will then be securely destroyed.

We also want to make sure that your personal information is kept up to date and therefore if your details change please do let us know.

You have the right to request a copy of the information we hold about you. Please contact us if you wish to receive this.