Arts and Wellbeing Referral Form (2025)
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
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31st
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
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2016
2015
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2012
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1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
How would you describe your sexual orientation?
Please Select
Heterosexual / Straight
Homosexual (Gay/Lesbian)
Asexual
Bisexual
Queer
Questioning
Pansexual
Prefer not to say
Other
Gender
Please Select
Male
Female
Nonbinary
Genderqueer
Two-Spirit
Prefer not to say
Genderfluid
Agender
Cultural background
Please Select
White British
Scottish
Irish
White Other Background
Black African
Black Caribbean
Black British
White and Black Caribbean
White and Black African
Mixed Race
Black Other Backrgound
White/Asian
Asian British
Bangladeshi
Indian
Chinese
Asian Other Background
Prefer not to say
Address
Address 1
Address 2
Town
Borough
Post Code
Mental Health Services
Is the participant currently engaged with mental health services
Please Select
Yes
No
Prefer not to say
Which borough is/was this service located?
Contact
Email
Mobile
Preferred method of contact
Mobile
Telephone
Email
Emergency Contact
Full Name
Relationship to Participant
Mobile
Email
Content Consent
I give my consent / permission for my artistic content created during Raw Material sessions, to be used if required on the Raw Material social media and website
Please Select
Yes
No
Prefer not to say
Demographic
Do you identify as any of the following?
Unwaged / Low Income
Excluded from School
Attending a Pupil Referral Unit (PRU)
NEET (Neither in Education, Employment, or Training)
Young Offender / At Risk of Criminal Activity
Special Educational Needs / Disability (SEND)
LGBTQ+
Looked After (In Care)
Young Carer
English as a Second Language
Refugee
Asylum Seeker
Homeless
Traveller / Romany
Prefer not to say
Other
None of the above
If you selected other please specify
Medical/Dietary needs
Do you have any special medical or dietary needs we should know about?
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
Does the client have a history of violence and aggression?
Please Select
Yes
No
Prefer not to say
Does the client misuse drugs/alcohol?
Please Select
Yes
No
Prefer not to say
Has the client made specific threats to harm others?
Please Select
Yes
No
Prefer not to say
Has the client recently been discharged from hospital (within the last 6 months)?
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
Does the client present a risk of inappropriate sexual behaviour?
Please Select
Yes
No
Prefer not to say
Is there a risk of exploitation from others (financial, sexual, physical, emotional)?
Please Select
Yes
No
Prefer not to say
Does the client have a history of non-compliance with aftercare?
Please Select
Yes
No
Prefer not to say
Does the client feel comfortable in a group setting?
Please Select
Yes
No
Prefer not to say
Relapse indicators
Trigger factors
Summary of risk
Support
Do you have any additional requirements in order to participate?
Media Consent
I give my consent / permission for photos and videos to be taken during the project, to be used if required on Raw Materials’ social media and website
Please Select
Yes
No
Prefer not to say
Programme
Please select your FIRST choice of Raw Sounds project
Please Select
Beat Lab
DJing
Guitar Sessions
Mindful Music
Producer Accelerator
The Voice
Vibe Alliance (Band Project)
Please select your SECOND choice of Raw Sounds project
Please Select
Beat Lab
DJing
Guitar Sessions
Mindful Music
Producer Accelerator
The Voice
Vibe Alliance (Band Project)
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
Was this form completed by a participant or care coordinator?
Please Select
Participant
Care Coordinator
Someone Else
How did you hear about Raw Material?
Submit