Garden for wellbeing application 2021

Preferred start date

Client details

Title

Forename *

Known as

Surname *

Date of birth *

Gender

Male Female Other

If other, please specify

Client Email (If you do not have the client email address, please leave blank and enter your email address under welfare/referrer email.)

Phone Number

Mobile number *

Street Address *

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/referrer email address

Welfare contact number

Welfare contact relationship to client

Please outline the outcomes you are hoping for from time spent at The Therapy Garden *

Please outline any particular interests and pastimes that you enjoy eg. gardening, walking, cookery, crafts

Where did you hear about The Therapy Garden? *

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 any health/medical needs

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

Do you have 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 of how this condition affects you and 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.

Do you have any special dietary requirements?

Yes No

If the answer is YES, please give details.

Date of last tetanus injection (if known)

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

Have you 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

Garden for wellbeing form

Client details

Medical information

Other details

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