Referral form

Greater Manchester Nature for Health: Referral form

If you are filling out a form to refer yourself, then head to our self-referral form.

Details of person being referred

Details of referrer

Has the individual consented to this referral?
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.
Is being with a group of six people okay?

Known safeguarding issues

Risk to self

Self neglect
Self harm
Suicide attempt
Drug/alcohol misuse
Isolation

Risk/abuse from others

Physical
Financial
Sexual
Other

Risk to others

Is there potential for violent or aggressive behaviour?
Are there any concerns regarding safety to work alone?
Are there any concerns regarding safety to work alone in a group?

Risk to property

Theft
Damage
Other

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
Ethnicity
Disability and impairment
Do you identify yourself as a deaf or disabled person?
Sexuality
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?
Are they under 18?
Please tick box to indicate.
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