Arts and Wellbeing (Referral Form)
Identity
First Name
Last Name
Pronouns
Please Select
He/Him
She/Her
Them/They
Which name do you like to be known as?
Date Of Birth
Day
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
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27th
28th
29th
30th
31st
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
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2005
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2002
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1931
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1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
Do you identify as LGBTQIA+?
Please Select
Heterosexual / Straight
Gay Woman / Lesbian
Gay Man
Bisexual
Queer
Transgender Female
Transgender Male
Prefer not to say
Demographic
Gender
Please choose a value
Female
Male
Nonbinary
Female Transgender
Male Transgender
Prefer not to say
Cultural background
Please Select
Asian/Asian British
Black/African/Caribbean/Black British
Prefer not to say
White
White and Black African
White and Black Caribbean
Mixed Race
Address
Address1
Address2
Post Code
Housing Association
Please Select
Ekaya HousingAssociation Ltd
Angell Town RMO Ltd
Barbican Estate Office
Ash Shahada Housing Association
Parkhill Housing
Viridian Housing
Shaftesbury Housing Group
Thorlans Housing Management Society
Camberwell Neighbourhood Office
Guinness Trust
Loughborough Estate Management
Unknown
Not Applicable
Contact
Email
Mobile
Emergency Contact
Full Name
Relationship to Participant
Mobile
Email
Preferred method of contact
Mobile
Telephone
Email
Mental Health Services
Is the participant currently engaged with mental health services
Please Select
Yes
No
Prefer not to say
Which borough is this service located?
Care Co-ordinator/Key Worker
Care Co-ordinator/Key Worker
Please Select
Yes
No
Prefer not to say
First name
Last name
Job title
Contact number
Email address
Service name/department
Risk Assessment
History of violence and aggression
Please Select
Yes
No
Prefer not to say
Misuse drugs/alcohol
Please Select
Yes
No
Prefer not to say
Specific threats to harm others
Please Select
Yes
No
Prefer not to say
Discharged from hospital
Please Select
Yes
No
Prefer not to say
Has the client recently disengaged with care/stopped medication?
Please Select
Yes
No
Prefer not to say
Risk of inappropriate sexual behaviour
Please Select
Yes
No
Prefer not to say
Risk of exploitation (financial, sexual, physical, emotional)
Please Select
Yes
No
Prefer not to say
Disengaged with care/stopped medication
Please Select
Yes
No
Prefer not to say
Comfortable in group setting
Please Select
Yes
No
Prefer not to say
Relapse indicators
Trigger factors
Summary of risk
Medical/Dietary needs
Do you have any special medical or dietary needs we should know
Support
Do you have any additional requirements in order to participate?
Programme
Why you are interested in this project?
I can commit to all sessions throughout the term, and understand that if I do not attend, my position will be offered to another member.
Please Select
YES
NO
Are you aware of the 10 pound membership fee to take part in Raw Sounds?
Please Select
Yes, I will pay the 10 membership at my first session (Cash and Card are accepted)
No, I cannot afford the 10 membership fee and I would like to apply for a bursary.
Please select your FIRST choice of Raw Sounds project
Please Select
Beats to E.P
DJing
Guitar Sessions
Mindful Music
The Voice
Please select your SECOND choice of Raw Sounds project
Please Select
Beats to E.P
DJing
Guitar Sessions
Mindful Music
The Voice
Submit
