Referral form | The Bay wellbeing programme

The Bay funders and partners logos - revised with new Trust logos 281122

The Bay wellbeing programme

Refer yourself or someone else

The Bay wellbeing programme referral form

Please use this form to refer onto the The Bay programme. If you have any questions, please don't hesitate to get in touch with The Bay programme's Nature & Wellbeing Officer, Jessica Mordain. You can contact Jessica by email at jessicam@cumbriawildlifetrust.org.uk or telephone 07717 019691

Are you completing this form on behalf of someone else (including a parent/guardian)?

Yes

Your details

First name

Last name

Date of birth

Address

Please include first line, town and county.

Postcode

Contact email

Contact telephone number:

How did you hear about us?

How would you like to get involved?

There are a number of ways you can get involved with us. Please choose the option you would be most interested in from the list below.

What do you hope to gain from attending nature and wellbeing sessions?

Details of person being referred

Participant first name

Participant last name

Participant date of birth

Participant address

Please include first line, town and county.

Participant postcode

Participant contact email

Participant contact number

How did they hear about us?

Details of referrer

Referrer first name

Referrer last name

Referrer position/team

Referrer organisation name

Referrer organisation address

Referrer contact email

Referrer contact number

Has the individual consented to this referral?

Yes

How would they like to get involved?

There are a number of ways they can get involved with us. Please choose the option they would be most interested in from the list below.

What do they hope to gain from attending nature and wellbeing sessions?

Is being with a group of six people okay?

Yes

Details of allergies, physical or mental health concerns, learning disabilities or other needs:

Known safeguarding issues

Risk to self

Self-neglect	Self-harrm	Suicide attempt	Drug/alcohol use	Isolation
Self neglect	Self-harm	Suicide attempt	Drug/alcohol abuse	Isolation

Risk/abuse from others

Physical	Financial	Sexual	Other
Physical	Financial	Sexual	Other

Risk to others

Is there potential for violent or aggressive behaviour?	Are there any concerns regarding safety to work alone?	Are there any concerns regarding safety to work alone in a group?
Is there potential for violent or aggressive behaviour?	Are there any concerns regarding safety to work alone?	Are there any concerns regarding safety to work alone in a group?