Farm Therapy Referral Form

Applicant Details

Applicant Name (required)

Date of Birth (required)

Applicant Ethnicity
AsianAsian-BritishBlack-BritishBlack-AfricanBlack-CaribbeanOther Black BackgroundChineseWhite-BritishOther White BackgroundOther Ethnicity GroupDo not wish to answer

Home Address

Phone Number (required)

Mobile Number

Email Address

Background Information

Employment History

Employment Status
UnemployedOff SickWorkingOther

Hobbies & Interests

What are you hoping to get out of Farm Therapy?

How many sessions would you like to book?

Are you filling this form out on behalf of someone else?
NoYes

Medical Information

Mental Health Diagnosis

Are you taking any medication?

Any physical health problems that we should be aware of?

GP Name

GP Address

Are you seeing anyone else in relation to your mental health?
NoYes

I agree to Clinks Care Farm keeping my details whilst participating in Farm Therapy.

For further information or queries, please contact Iris van Zon on 01502 679134 or per email iris.vanzon@clinkscarefarm.org

Please leave this field empty.