Adult Client application form

So we can provide the best possible service and keep everyone safe, please include as much information as possible. All information provided is confidential and will only be shared with The Therapy Garden Manager, staff who need to know and Chair of Trustees, if applicable.

Client referral 2021 step 1

Client details

Title

Forename *

Known as

Surname *

Date of birth *

Gender

Male Female Other

If other, please specify

Email (Please do not enter your own email address here if you are completing the form for someone else. There is space for this in the referrer section below.)

Phone Number

Mobile number (if this referral is for a child or young adult under 18 please enter 0) *

Street Address *

Address Line 2

City

County

Post Code *

Country

ICE or next of kin name *

ICE phone number *

ICE relationship to client *

In the event of sickness or absence who should we contact (if different from ICE or next of kin)?

Welfare contact name

Welfare contact number

Welfare contact relationship to client

Please outline the outcomes you, the family and the young person/client are hoping for from time spent at The Therapy Garden

Referrer details

If this is a self referral please provide details of any social workers, care coordinators, health professionals or GP we can contact to obtain any further information required to assess your level of support needs.

If you do not consent for us to make contact with anyone else or if there is no one appropriate to talk to please tick below and move on to the transport section.

I do not consent I consent

Referrer name

Job title

Organisation

Address

Postcode

Phone number

Where did you hear about The Therapy Garden?

Transport details

What will be the transport arrangements for the client to get to and from the centre? (Transport is to be organised by the school/carer/key worker at no cost to The Therapy Garden, unless arranged with the Therapy Garden Manager) *

Contact's name

Address

Postcode

Phone number

Mobile number

Please include any out of hours, duty worker or emergency numbers available.

Adult Client application form

Client details

Referrer details

Transport details

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