The Cart Shed: Self Referral Form

PLEASE READ BEFORE SUBMITTING A REFERRAL TO ENSURE THAT WE ARE THE RIGHT SERVICE FOR YOU OR THE PERSON YOU ARE SUPPORTING

Level of Support

We are charitable organisation providing a basic Tier 1 mental health service. We endeavour to support as many people as we can, and referrals are considered on an individual basis, however the nature of our environment, our staffing levels, the type of provision we offer, and the fact that our Young Cart Shed provision runs alongside our adult provision, means there are some individuals we are unable to work with.

Please be aware that we cannot work with:

· Individuals that pose a risk to children or young people.

· Individuals with a history of sexual offending.

· Individuals that are aggressive or violent and pose a risk to our team or participants.

Referral for individuals that fall into the above categories will not be accepted.

Please be aware that for anyone that is being supported by Probation services, we require a full risk assessment from Probation at the point of referral so that we can make an informed decision as to the suitability of that individual for our service. We can only consider those that Probation has assessed as low risk to others. Without this risk assessment information, the referral will be rejected as incomplete.

· Individuals in mental health crisis, especially if they are not receiving support elsewhere. We are able to sign post and refer on but have limited capacity to provide ongoing 1:1 mental health support. The interventions we provide are predominantly activity and group-based with a focus on mental health promotion, so primary or specialist mental health support needs to be provided by a statutory or private service.

· Individuals presenting with predominantly behavioural issues. Behaviours of any sort that cause distress to other participants or that are disruptive to service provision and that cannot be moderated effectively following intervention, will result in the placement being withdrawn. We need to ensure that we maintain a welcoming, safe, non-judgemental and therapeutic space for our service users.

· Individuals requiring 1:1 support on site. Individuals need to be able to manage the site, facilities, tools and activities safely and with minimal support. We have a low staff to participant ratio, so our focus is on facilitating engagement in the activities on offer and we have limited capacity to provide individual support beyond this.

· Individuals requiring ongoing support from a support worker or personal assistant on site. Beyond Taster Days and transitions periods where we can accommodate external 1:1 support to help get individuals started and settled with us, we cannot work with those that need this level of external 1:1 support on site on a longer-term basis. We need to manage numbers on site so that sessions are not too busy or overwhelming for participants. Regularly having additional people on site has a detrimental impact on the therapeutic group dynamic we aim to create.

Individuals with complex physical health needs. Managing complex physical health needs in a woodland setting can be challenging due to uneven terrain, unpredictable weather, and limited accessibility including steps to access toilets on all sites. Individuals must be able to take responsibility for and self-administer any medication they require and be able manage personal care tasks, such as feeding themselves and using the toilet, independently. Certain types of specialist medical equipment (such as oxygen tanks) are not suited to being in the woods due to the nature of our environment, which includes open fires. Please be aware that in these circumstances we may not be able to accommodate the request for a place, or to offer a place at certain times of the year because of weather conditions.

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.

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

Additonal Documents

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

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.