The Cart Shed: Self Referral Form

PLEASE READ PRIOR TO SUBMITTING A REFERRAL

Mobility

We are based outdoors in a woodland environment and as such the ground can be uneven, slippery and there can be trip hazards such as tree roots. Our environment may therefore not be suitable for those with poor mobility or poor balance, or those that need certain types of walking aids such as rollator frames. We have open fires on site, so are cautious about accepting referrals for individuals that experience falls or seizures. There is a walk of about 100m from the car park to the woodland site that individuals need to be able to manage.

There are composting toilets on site that are on raised platforms with four 6” steps to access, so individuals need to be able to manage steps independently in order to be able to use our toileting facilities.

Transport

We offer free transport from designated pick-up points in Hereford, Leominster and Kington only, so individuals need to be able to get to one of these pick-up points in order to be able to use our transport. They also need to be able to get on/off of the transport safely and independently.

Level of Support

We endeavour to support as many people as we can, and all referrals are considered on an individual basis. However, there are some individuals we are unable to work with due to the nature of our environment, our staffing levels, or the risk some individuals may pose to others, especially in relation to the children and young people we have on site as part of our Young Cart Shed provision.

Welcome to the Cart Shed!

We are delighted that you are interested in attending one of our courses. Before we can register you on to one of our courses, we need to ask for a few key details from you.

Please can you complete the form below; either for yourself or on behalf of someone.

Are you completing this form for

YourselfSomeone else (18 or above)Someone else (Under 18)

If you are completing this form for someone else please provide your contact details below

Title

First Name

Middle Name

Last Name

Contact Number

Relationship to you

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 of Participant

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

Emergency Contact Details

Title

First Name

Last Name

Home Phone (Landline numbers only)

Mobile Phone

Relationship (friend, partner, etc.)

Transport Details

Transport Required getting to/from The Cart Shed

If yes, please indicated preferred pick up point below

Armed Forces Connection and Blue Light Community

Armed Forces Connection - please tick any that apply

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)

NoYes

Which sector do you work in?

Involvement with Agencies

Telling us about the services you've used or are currently using helps us get you started quickly. Rest assured, having used these services now or in the past does not disqualify you from attending.

Please confirm you have read this statement

Have you had any previous or current involvement or support from any of the following? Please provide contact details of anyone currently supporting you.

CPN

Name and Contact Details of Case Worker (CPN)

Social Worker

Name and Contact Details of Case Worker (Social Worker)

Mental Health Services

Name and Contact Details of Case Worker (Mental Health Services)

Drug and/or Alcohol Services

Name and Contact Details of Case Worker (Drug and/or Alcohol Services)

Social Care Services

Name and Contact Details of Case Worker (Social Care Services)

Criminal Justice System

Name and Contact Details of Case Worker (Criminal Justice System)

Probation Services

Name and Contact Details of Case Worker (Probation Services)

Background information

Education/employment details

Current benefit status

Current Mobility - Please describe mobility indoors and outdoors, what mobility aids are used and when (if relevant) and details of any falls within the last 3 months

Supporting you and keeping everyone safe

The more information you can provide us with, the quicker and easier it is for us to screen your referral incomplete information will mean that we will need to pass the referral back to you.

Within the past year have any of the following been an issue for you: * not being able to manage your self-care, * hurting yourself, * thinking about or acting on thoughts to take your own life, * being violent towards others, * being purposefully unkind to others, *misusing substances.

If ‘yes’ please provide brief details. if 'no' please write n/a

Reasons for wishing to attend The Cart Shed

What do you think we can offer that would be beneficial to you?
Do you have any particular support needs that it would be helpful for us to know about?

Feel free to write as much as you want here

Reasons for wishing to attend The Cart Shed

What do you think we can offer that would be beneficial to you?
Do you have any particular support needs that it would be helpful for us to know about?

Feel free to write as much as you want here

How you found out about the course

Please tell us how

Voluntary Contributions welcome

We have introduced a voluntary contribution scheme for everyone who wants to support the running cost of the Cart Shed Charity. 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, they are still welcome. Donations and referrals are not linked.

Information on how to donate will be given to you shortly after you enrol with us. If for any reason this causes you any anxiety, please raise it with one of the team immediately.

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.