Client details

Title

Date of birth

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

Address Line 2

City

County

Country

ICE or next of kin

Client referral

Please let us know who has referred you to The Therapy Garden. We will need some information from them so need their contact details.

Name

Job title

Organisation

Address

Postcode

Phone number

Email

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 carer/key worker at no cost to The Therapy Garden, unless arranged with the Centre Manager)

Contact's name

Address

Postcode

Phone number

Mobile number

Email

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

Medical information

Please give a summary of mental health problems/learning difficulties/physical disabilities/special needs/health etc

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

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

Please give details of any medication that has been prescribed

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

If the answer is YES, please give details below

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

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 this here.

Restrictions for acceptance of clients

Please click here to 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.