Electronic Self Referral Form

If you are interested in benefitting from some of the amazing offerings Muddy Fork can provide you with, please complete the referral form below and one of our team will get back to you as soon as possible.

Name

Address (Including Postcode)

Date of Birth

Ethnicity

Email Address

Contact Number

Do you access support from any Health Service/Community Organisation in connection with your mental health/wellbeing? If so, please tell us about them below.

Name, address and contact number of the Health Service or Community Organisation

Name, job title and contact details of Health or Community Support Worker

Are they willing to be our main contact during your time with Muddy Fork?

Yes

No

If no, would you like a friend or family member to be our main contact?

If so, please tell us about them below.

Name, relationship to you and contact details

Name of GP, surgery address and contact number

Please tell us why you would like to join Muddy Fork - what prompted you to enquire?

Nature of your mental health and wellbeing issues.

Please share details of any diagnosis if you have one. If you do not have a diagnosis, please describe your mental health and wellbeing concerns at the moment.

About you - Please share with us a little bit about your circumstances.

For Example, Do you live alone?, Are you employed or a volunteer?, Are you a carer for children or friends and family?

Safeguarding issues.

Please tell us about anything we need to know to keep you safe.

Your individual needs.

Allergies, physical health problems (e.g., back pain, diabetes, epilepsy), physical or learning disabilities or other support needs, and any medication that we should be aware of.

Is your tetanus up to date?

Yes

No (If no, please take advice from your GP)

Name of Next of Kin / Emergency Contact

Contact Details for Next of Kin / Emergency Contact

Thank you for completing this form.

The information supplied will be kept in the strictest confidence and in accordance with Muddy Fork data protection policy.

Our Privacy Policy applies.

Note: Please fill out the fields marked with an asterisk.

How to find us

Muddy Fork,

Idle Valley Nature Reserve,

North Road,

Retford,

DN22 8SG