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Out of the Blue attendance enquiry

Sign up - Out of the Blue

Use this form to sign up for sessions for adults aged 18 or over who want to look after their mental health and wellbeing.

Please select your role

I am Referring to Out of the Blue from an Organisation

I am Self Referring to Out of the Blue

Attendee details

OOB Current Status

Referral made

Made an Enquiry

First Name

Last Name

Birth Date

Street Address

Street Address Line 2

City

Postal Code

Country

Phone Number

Mobile Number

Email (please leave blank if you/they do not have an email address)

Do you/they have a Keyworker, CPN or Social Worker?

Yes

No

Keyworker/CPN Details

Key Worker/CPN Name

Key Worker/CPN Address

Key Worker/CPN Contact Number

Key Worker/CPN Email

Has the Keyworker carried out a risk assessment?

Emergency Contact Details

hoot may contact an emergency contact if we have concerns regarding your helath whilst attending the service. Please inform the emergency contact listed here that their details have been given to hoot for this purpose.

Emergency Contact Name

Emergency Contact - Relationship to You

Emergency Contact Contact Phone Number

Attendance

Have they attended Out of the Blue activities before?

Which activities are they interested in?

Creative Writing

Digital Music

Music

Singing

Visual Arts

Don't Know

Activity

Part 1: Which of the following applies to the applicant?

Part 2: Which of the following applies to the applicant?

I am currently experiencing issues with my mental health/I have been diagnosed with a mental health condition

I would like to help to prevent mental health issues and maintain my wellbeing

Neurodiverse Condition

Physical Disability

Learning Disability

Dementia

Mental Health Issues

None apply

Have you/they got a Community Care Assessment (CPA)?

Please describe any communications needs you/they might have

Eligible for Direct Payments/Personal Budget?

Is there anything you would like us to know to help us to support you at hoot?

Have you accessed any other services in Kirklees?

Active For Life

Community Links - Clear

Richmond Fellowship

Support 2 Recovery

St Anne's Community Services

Touchstone

Women Centre

Other (please specify)

None of the above

Other service accessed in Kirklees

Referrer Details

First Name

Last Name

Phone Number

Email

Referral Source - please select the relevant option

Referral Source (other text)

Referrer Organisation Details

Organisation Name

Street Address

Street Address Line 2

City

Postal Code

Risk Factors

Has the client undergone a Risk Assessment from your service?

Yes

No

Reasons for Referral

What do you think they will gain?

Summary of current presenting issues

Do they pose a risk to themselves? Please select from the dropdown menu

Do they pose a risk to themselves?

Do they pose a risk to others? Please select from the dropdown menu

Do they pose a risk to others?

Does this person have on-going support from your services?

Yes

No

Any other information you think we should know?

I confirm that the person I am referring is able to participate in Out of the Blue activities independently, or will be provided with the appropriate support. (Contact hoot if in doubt)

Dignity & Respect
hoot believes everyone participating in our activities should be treated with dignity and respect. Verbal abuse, bullying and aggression towards staff, volunteers or other participants is unacceptable, and constitutes grounds for exclusion from all activities.

The data submitted on this form will be stored securely in hoot creative arts' database in order to process your referral and contact you with regards to attending sessions. You can read our Privacy Policy here.

How did you hear about us details

How did you hear about us?

How did you hear about us? Other: Please specify

By telling us how you heard about hoot and our sessions you will be helping us to evaluate our publicity and marketing and make changes to improve visibility and accessibility.

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Where we are

hoot creative arts
Bates Mill,
Milford Street
Huddersfield
HD1 3DX

Contact

Telephone: 01484 516 224
E-mail: info@hootcreativearts.co.uk

Our funders

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Hoot Creative Arts is a Registered Charity - Charity Number 1146358
Hoot Creative Arts Ltd - Registered in England 07980273

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