Details of referrer Referrer first name Referrer last name Referrer position/team Referrer organisation name Referrer organisation address Referrer contact email Referrer contact number Has the individual consented to this referral? Yes No Details of person being referred Participant first name Participant last name Participant Date of Birth (DD/MM/YYYY) Participant address Participant town Participant postcode Participant contact email Participant contact number Has the person you are referring already identified which nature based group they would like to join? - Select -Incredible Edible Prestwich and DistrictLancashire Wildlife Trust – green wellbeingLancashire Wildlife Trust – practical conservationFriends of Philips ParkBury Greenwood SocialTuesday social drop in There are a number of ways you can get involved with us. Please choose the option you would be most interested in from the list below. What do they hope to gain from attending nature and wellbeing sessions? Details of allergies, physical or mental health concerns, learning disabilities or other needs Known safeguarding issues Risk to self Self neglect Yes No Self harm Yes No Suicide attempt Yes No Drug/alcohol misuse Yes No Isolation Yes No Risk/abuse from others Physical Yes No Financial Yes No Sexual Yes No Other Yes No Risk to others Is there potential for violent or aggressive behaviour? Yes No Are there any concerns regarding safety to work alone? Yes No Are there any concerns regarding safety to work alone in a group? Yes No Risk to property Theft Yes No Damage Yes No Other Yes No Is there anything else you may wish to tell us about? Equal opportunities In accordance with Lancashire Wildlife Trust’s policy on equal opportunities, we will provide equal opportunities to any participant and will not discriminate either directly or indirectly on the grounds of race, colour, ethnic origin, nationality, national origin, sex, sexual orientation, religion or belief, marital status, civil partnership, age, gender reassignment or disability. We would therefore be grateful if you could complete the questions on this form. All information will be treated in confidence and is collected for project monitoring purposes only. Gender Female Male Non-binary Prefer not to say Not known Ethnicity White of British Origin White of Irish Origin Irish Traveller White of Any Other Origin Mixed Race of White and Black Caribbean Mixed Race of White and Black African Mixed Race of White and Asian Mixed Race of Any Other Origin Asian / Asian British of Indian Origin Asian / Asian British of Pakistani Origin Asian / Asian British of Bangladeshi Origin Asian/Asian British – Chinese Asian/Asian British – any other Asian background Asian/Asian British of Any Other Origin Black / Black British of African Origin Black / Black British of Caribbean Origin Black / Black British of Any Other Origin Other – Arab Other - Cornish Other – Any other ethnic group Other - prefer not to say Other - not known Disability and impairment Yes No Prefer not to say Not known Do you identify yourself as a deaf or disabled person? Sexuality Bisexual Gay man Gay woman/lesbian Heterosexual/straight Prefer not to say Not known Other Pronouns Which pronouns do you prefer to be referred to as? This helps us to know the best way to address you. For example: Your pronouns would be she/her if you'd like us to say, 'Yes, it's her bag, she left it here' in the event of you leaving your bag behind one day. Referral next steps - who should we contact? Referrer Individual Are they under 18? Yes No Please tick box to indicate. If they are under 18, please tick this box to indicate you have received parent/guardian consent to get in touch with us Parent/Guardian full name (if applicable) Parent/Guardian contact number (if applicable) Parent/Guardian contact email (if applicable) Leave this field blank
