The Cart Shed: Agency Referral Form

Mobility
Our environment may not be suitable for those with poor mobility. There is a short walk from where cars/minibuses park to each site and, as this is a wood, the ground can be uneven and sometimes muddy.
We can arrange transport but only from set pick-ups in Hereford, Leominster and Kington.
Participants also have to be able to manage a few steps to be able to access our compost loos. Participants need to cope independently.
Our taster sessions help us to assess their suitability before they begin working with us but please consider whether our environment would be safe for them.

Level of Support
We try to support as many people as we can, however there are some people we cannot work with due to the complexity of their needs and the risk they may pose to others.

As a Tier 2 mental health organisation, we do not work with:
- People with complex physical health needs that require a multidisciplinary approach
- Anyone needing 121 support - we work with groups and the size of our sites mean we cannot always accommodate support workers alongside participants.
- Those who are violent and/or aggressive and pose a risk to our team or other participants. Anything classed as medium risk and above cannot be accommodated.
- Anyone posing a risk to children
- Anyone in mental health crisis who is not receiving support elsewhere
- Anyone under Probation unless we have full disclosure and can assess them as low risk

Contact Details of Person Registering with The Cart Shed for a Course

Name and Date of Birth

Title

First Name

Middle Name

Last Name

Date of Birth

Gender

Preferred Pronoun (optional)

Address

Mailing Street

Mailing City

Mailing County

Mailing Postal Code

Email and Phone

Personal Email

Home Phone (Landline numbers only)

Mobile Phone

Preferred Phone

Preferred Method of Contact

Preferred Method of Contact - Other

GP Details

GP Surgery Name

GP Surgery Postcode

GP Name

Transport Details

Assistance Required getting to/from The Cart Shed

If yes, please indicated preferred pick up point below

If you selected Other, please provide details (eg, within vicinity, e.g., Weobley)

Emergency Contact Details

Title

First Name

Last Name

Home Phone (Landline numbers only)

Mobile Phone

Relationship (friend, partner etc)

IT Support

All of our courses require participants to complete paperwork for our funders. To reduce the amount of paperwork participants may be asked to complete whilst in the woods they may be asked to fill this paperwork in digitally prior to the course starting. Additionally, during lockdown our services moved online whilst we were unable to run our courses in our woodland. We have contingencies in place to facilitate this again in case we enter another lockdown. We also plan to continue to offer some courses and support remotely to participants who need to continue to "shield".

So that we can better understand your digital needs, please confirm which of the following you have:

Access to the internetAn email address that paperwork can be sent toA computer / tablet / phone that they can use to complete paperwork

Covid 19

To ensure the safety of our staff, volunteers and participants, The Cart Shed has introduced measures in response to COVID-19 that all must adhere to. Our policies are amended as advice from the government is updated. If your answers to the below questions change prior to starting or during a course with The Cart Shed, we ask that the participant to let us know as soon as possible. Please read the statements below and check the boxes for all that apply.

Identify as clinically extremely vulnerable

High Risk from Covid-19Moderate risk from Covid-19Received a letter from government instructing to shieldLive with someone at high risk from Covid-19We require anyone who received a positive test result to share this with The Cart Shed in line with the nationwide NHS Test and Trace procedure. If they are not prepared to share please tick.

Voluntary Contributions

From the feedback we receive we know how valued our services are by all involved in them. The Cart Shed charity relies on fundraising to enable those who do not qualify for social care support to attend sessions.

We are asking every participant to consider donating what they can to help with the costs of their course. This is not mandatory. If a participant cannot afford even the smallest of donations, we still welcome the referral. Donations and referrals are not linked.

Information on how participants can contribute will be given to them shortly after they enrol with us. Please make this known to you client, so it doesn’t come as a surprise. Information on how to donate will be given to the participant shortly after they enrol with us.

Please check this box to confirm this information has been shared with the client.

Armed Forces and Blue Light Community

Armed Forces Connection

Currently ServingVeteranFamily of Serving or Ex-serving Member

Do you currently work for the Blue Light community? Emergency services, NHS, social care sector and armed forces (Please go to https://www.bluelightcard.co.uk/ to see who is included)

YesNo

Which sector do you work in?

Reason for Referral

Reasons For Referral / Needs Identified

Relevant Background Information

Risk Assessment

Additional Documentation

Where relevant and possible please attach copies of EHCP’s, CPA’s, Crisis Plans, Care Plans and any other assessment or reports.

Other Agencies involved (such as educational, medical or social services)

Title

First Name

Last Name

Job Title

Organisation Name

Role

Contact Number

Referrer's Details

Title

First Name

Last Name

Job Title

Organisation Name

Contact Work Number

Add Another Contact Number

Contact Work Mobile Number

Preferred Method of Contact

Preferred Method of Contact - Other

Address

Mailing Street

Mailing City

Mailing County

Mailing Postal Code

Data Protection

The information that is shared with The Cart Shed during the referral process is requested in order to enable provision of appropriate occupational therapy assessment and intervention. It will not be utilised in any other form than for the purpose for which it is collected. If it should become beneficial or necessary to share information with other healthcare professionals, social or welfare organisations this will be done in compliance with the Information Commissioner’s Office GDPR Regulations 2018. All information collected will be held securely.