Referral Form for wellbeing workshops

Please enter the date of referral (normally today's date)

Which programme are you interested in? Which programme are you interested in?Crafting for WellbeingDrama for WellbeingDrumming for WellbeingWoodwork for WellbeingWriting for WellbeingMore than one - please note in other information below

First name(s) of individual

Surname(s) of individual

Client contact telephone number

Email, if applicable

Gender GenderMaleFemaleOther (please note in other information below)

Home Country

Ethnicity EthnicityIndian or British IndianPakistani or British PakistaniBangladeshi or British BangladeshiChinese or British CitizenAny other Asian BackgroundBlack CaribbeanBlack AfricanAny other Black, Black British, or Caribbean backgroundMixed White and Black CaribbeanMixed White and Black AfricanAny other Mixed or Multiple Ethnic backgroundWhite English, Welsh, Scottish, Northern Irish or BritishWhite IrishGypsy or Irish TravellerRomaAny other White backgroundArabAny other ethnic group

Language(s) spoken

Date of Birth (DD/MM/YYYY)

Immigration status (if known) eg. asylum seeker, refugee, leave to remain, British Citizen

Who referred you to us? / How did you find out about us?

Please provide details of any food intolerants? (for refreshments purposes)

Phone number and name of a contact for emergencies

Is there anything we should know about your ability/the ability of the person you are referring to be able to access our wellbeing services?

Form completed by (name and role)

Data protection - we are committed to treating your personal data effectively under UK GDPR. The above data helps us to ensure we can support you effectively on your wellbeing journey. We may also use your data for statistical analysis/monitoring purposes. Your data will not be shared with third parties without informing you. Please indicate below your consent to our retaining your data for these purposes. For more details about our Data Protection Policy, or to withdraw consent, please contact the Data Protection Officer at kaleidoarts@protonmail.com. Data protection - we are committed to treating your personal data effectively under UK GDPR. The above data helps us to ensure we can support you effectively on your wellbeing journey. We may also use your data for statistical analysis/monitoring purposes. Your data will not be shared with third parties without informing you. Please indicate below your consent to our retaining your data for these purposes. For more details about our Data Protection Policy, or to withdraw consent, please contact the Data Protection Officer at kaleidoarts@protonmail.com. I consent to Kaleido Arts for Wellbeing retaining my personal data as outlined above.