Self-Referral Form: Radiate Arts

Self-Referral Form

Please complete the form below so we can understand your interests and support needs and match you with the most suitable sessions. All information shared will be kept confidential and used only to support your participation

Date of referral

Month

Day

Year

First name

Last name

Birthday

Month

Day

Year

What Are Your Pronouns?

Address

Phone

How would you like creative activities to support your wellbeing or recovery?

Are there any risks to you or anyone else's safety that we should be aware of?

Yes

Unsure

If yes, please share more information.

Other relevant information that you would like us to know at this stage:

I confirm that the information provided is accurate to the best of my knowledge and will help Radiate Arts provide appropriate support.

Radiate Arts will use this information to process the referral and provide appropriate support. All information will be stored securely and handled in line with UK GDPR and data protection regulations. Information will only be shared with relevant partners where necessary and with consent.

View our privacy policy here.

Self-Referral Form

Date of referral

Month

Day

Year

First name

Last name

Birthday

Month

Day

Year

What Are Your Pronouns?

Address

Phone

How would you like creative activities to support your wellbeing or recovery?

Are there any risks to you or anyone else's safety that we should be aware of?

Yes

Unsure

If yes, please share more information.

Other relevant information that you would like us to know at this stage:

I confirm that the information provided is accurate to the best of my knowledge and will help Radiate Arts provide appropriate support.

View our privacy policy here.