Express an interest for yourself or refer someone you know to take part in our gardening therapy sessions

Please complete this form to enable us to check eligibility and up date you with details of our upcoming sessions

Participant Details

First Name

Last Name

Phone

Date of Birth

Address:

Emergency Contact Name & Phone Number:

Main reason for referral including any medical diagnosis if relevant:

Do you or the person you are referring have any other health issues we should be aware of eg insulin dependent diabeties, epilepsy, heart condition, back pain etc . . . ?

Do you or the person you are referring have a history of aggression, substance abuse, self-harm or any other personal circumstances we should be aware of? Please include (or email to info@natureshaven.net) a risk assessment or EHCP if one is in place:

Please tick to confirm that you/the individual you are referring consents to Nature's Haven processing your/their personal data:

If making a referral please add Referrer's name, position and organisation:

If making a referral: Referrer's Email:

If making a referral: Referrer's Phone Number:

Please tick to confirm that you/the individual you are referring will not attend any sessions if you/they are feeling unwell or showing symptoms of COVID-19

Please Note: no previous experience is required - the following information helps us to plan sessions and make it as rewarding for the participant as possible.

Which session(s) are you or the individual you are referring able to attend? Please note participants are welcome to attend both sessions

Is there anything in particular that you or the individual you are referring would like to learn during our sessions?

Adaptations - please let us know of any personal circumstances that may affect the ability of you or the individual you are referring to complete tasks. We can then make appropriate arrangements for them. If appropriate please provide the relevant section of the participant's EHCP:

Your Signature

Date:

* Required

Thank you for completing this form. You can either click the 'Submit' button below or email a copy to info@natureshaven.net

Thank you for completing this form. We will be in touch soon.

Express an interest for yourself or refer someone you know to take part in our gardening therapy sessions

* Required

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