Adult Client referral 2021 part 2

Name

Client email address

Medical information

In order for us to give the best service and keep everyone safe please provide as much information as possible.

Please give details of mental health needs (including any information about addiction or substance use that may have become problematic)

Please give details of any learning difficulties or additional needs

Please give details of any physical disabilities

Please give details of any health/medical needs

Please give details of any allergies, e.g. nuts, food, specific plants, materials, plasters etc

Has the Client had any of the following?

Asthma or bronchitis

Heart condition

Fit, fainting or blackouts including epilepsy

Severe headaches

Diabetes

Allergies to any medication

Back problems

Travel sickness

Other illness and disability

If the answer to any of the above is YES, please give details unless already covered above.

Does the client currently receive support for, or have a history of, self harm or suicidal behaviour?

Yes No

Does the client currently receive support for, or have a history of, violent or abusive behaviour?

Yes No

If you have ticked either of these boxes please provide full details below:

Please give details of any medication that has been prescribed

Is there any specific medical advice to follow in an emergency?

Yes No

If the answer is YES, please give details, including name and dosage of any medicines/tablets

Are there any special dietary requirements?

Yes No

If the answer is YES, please give details below

Date of last tetanus injection

Are there any specific triggers we need to be aware of? For example known triggers for epilepsy or triggers to certain behaviours or that may cause emotional distress.

Please let us know if there are any specific adaptations/tools or approaches required to provide the best service. I.E specific tools, grab rails, communication exchange methods.

Other details

Has the client ever been cautioned or convicted of a criminal offence or are there currently any criminal charges pending? *

Yes No

Is there anything else that we should be aware of? *

Yes No

If the answer is YES to either of the above, please give details

Data protection act

I agree to confidential information about my situation being kept on the confidential database at The Therapy Garden *

Yes No I am making a referral and cannot give consent at this time

I agree that information disclosed about me can be shared with relevant staff and volunteers to ensure that my needs are met while at the centre *

I agree

I agree to information about my situation being shared with the people listed below. *

Yes No

Please give the names of anyone with whom you would like the information to be shared. If you haven't already provided addresses for these people, please provide them here.

Photographic permission

I agree to photographs being taken in respect of activities undertaken by me whilst at The Therapy Garden, and that these photographs may be used for any publicity material for The Therapy Garden. *

Yes No I am making a referral and cannot give consent at this time.

Health and safety disclaimer

Click here to read the disclaimer. *

I accept the disclaimer I am making a referral and cannot give consent at this time.

Restrictions to acceptance

Please click here to read the restrictions for acceptance of clients. By clicking submit, I confirm that I understand these restrictions for use and that, to the best of my knowledge, all information provided is correct and the client is able to use The Therapy Garden.

Adult Client application form page 2

Medical information

Other details

Data protection act

Photographic permission

Health and safety disclaimer

Restrictions to acceptance