Apply to join a Pathways to Wellbeing Group

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Apply to join a Pathways to Wellbeing Group

Name (First and Last)(Required)

Address(Required)

City / Town(Required)

County(Required)

Postcode(Required)

Telephone Number(Required)

Email(Required)

Date of Birth(Required)

Which group would you like to join?(Required)

Gardener’s Lodge Art Group

IMAGE Art Group

Discover Museums – Mentored Volunteering Course

Please tell us about yourself and why you are interested in joining the group. As our groups are designed to support mental health and wellbeing, please share a little bit about your mental health and any related needs(Required)

Extra support: please tell us about any other access or support needs(Required)

Have you been referred or signposted to the group by a mental health / support worker / social prescriber? *(Required)

Yes

No, I am self referring

Name of referrer (if self-referring, please leave blank)

Referrer Job title & organisation

Referrer Telephone Number

Referrer Email

Are you currently being supported by any services?(Required)

Yes

Name of support / mental health worker

Telephone Number

Your Emergency Contact – Please provide the name of a family member or friend who we can contact in an emergency(Required)

Telephone number of emergency contact(Required)

Permission to contact this person in an emergency(Required)

Yes

Further information: if there is anything else you feel it is important for us to know, please share here

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