The Cart Shed: Self Referral Form


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.

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









Name and Date of Birth







Address




Email and Phone of participant (only complete if 18 years old or over)




Preferred Method of Contact


GP Details



Emergency Contact Details






How you found out about the course


Transport Details


Armed Forces Connection and Blue Light Community



Health information







Involvement with Agencies
Have you had any previous or current involvement or support from any of the following?







Please note that failure to disclose this information may prevent you from attending sessions, it will NOT prevent you from attending The Cart Shed if you have engaged with any of these services. 
Background information



Reasons for wishing to attend The Cart Shed

The more information you can provide us with, the quicker and easier it is for us to screen your referral and consider what our provision will be most suitable for you. Limited information may mean that we will need to pass the referral back to you.
  • 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?

  • ·     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.


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.

If you are having problems completing this form please contact us here