Green School Client form Aug 2018

Client details

Title

Forename *

Surname *

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

Mobile number *

Street Address *

Address Line 2

City

County

Post Code *

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

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

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

Has the Client had any of the following?

Asthma or bronchitis

Heart condition

Fit, fainting or blackouts

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.

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

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 information about my situation being kept on the confidential database at The Therapy Garden. *

I agree

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 would like to receive copies of any reports that are relevant to me. *

Yes No

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 this here.

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

Yes No

Health and Safety disclaimer
Click here to read the disclaimer. *

I accept the disclaimer

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.

Green School client registration form

Client details

Client referral

Transport details

Medical information

Other details

Restrictions for acceptance of clients