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Referral Form

Personal Details

Title *

Mr.MissMrs.Ms.

Name *Please enter a value

Date of Birth *Please select a date

Address (including postcode) *Please enter a value

Email Address

Contact Number (Please include area code) *Please enter a value

May we leave a message on the number you have provided *Please tick a checkbox

YesNo

Please provide any special instructions regarding your contact details

Emergency contact

Emergency contact (in the event of crisis) name

Emergency contact (in the event of crisis) Number (including area code)

In which circumstances can we contact your emergency contact (i.e. Medical emergency)

Referred for and Why

What do you think would help your well-being? *Please enter a value

Services

What Services would you like to access? *Please tick a checkbox

CounsellingOne-to-one Recovery ProjectGeneral SupportVolunteeringWork ExperienceWork PlacementCouples Counselling

Please note: only one life skills course can be taken per referral and One-to-one life skills are for 5 weeks of intensive support.

Life Skills

Anger ManagementResilience SkillsAssertiveness TrainingCoping with ChangeDecision MakingConfidence BuildingConflict ResolutionEmotional Well-BeingManaging StressTime Management

Life Skills Course type

GroupOne-to-oneBoth

Please provide details of why this referral is being made

Problems or needs

Do you suffer from any problems or needs and, if so, how are they affecting you?

Sensory LossMobilityProblems with reading or writingAnxietyMedical ConditionsAllergiesOther

Please state:

Associated Risk Factors

Please tick below if you have a history of any of these risk factors

Substance/Alcohol misuseSelf-harmSuicidal Ideation or intentViolence / AgressionSelf-neglectInnapropriate behaviorOther

Please state:

Other Support

Are you recieving support from any where else?

YesNo

If Yes, who with?

Would you prefer Daytime or evening appointments?

DaytimeEveningAny Time

Are you currently a member of Ponthafren Association?

YesNo

Form Completed by

Name of Referrer

Referring Organisation

Date of referral *Please select a date

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First name

Last name

Email

Find us

Ponthafren Newtown, Longbridge Street, Newtown, Powys SY16 2DY | +44 (0)1686 621586 | [email protected]

Ponthafren Welshpool, 42a Broad Street, Welshpool, Powys SY21 7RR | +44 (0)1938 552770 | [email protected]

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