1Email: therapy@animalsfortherapy.org.uk

Website: www.animalsfortherapy.org.uk

Animals for Therapy/Nature For Therapy Referral Form

Referrer detailsName: Job title:

Agency: Address:

Telephone: E-mail:

Date of referral:

How long have you worked with the client? (Please highlight) Less than 6 months 1-2 years

6 months to 1 year more

In what capacity? (Please highlight)

OT Social WorkerCPA Key worker GPCPN Psychiatrist Support Worker Hostel WorkerOther (please Specify)

AFT/NFT Referral Form V1.1

2

Client detailsMr/Ms/Miss/Mrs:

Name:

Surname:

Date of birth: Telephone:

Ethnicity:

White Black or Black BritishBritish Caribbean

Irish African

Any other white background Other Black or Black British

3

Asian or British Asian Other ethnic backgroundIndian Chinese

Pakistani Other (please specify below)

Bangladeshi

Mixed ethnicityNot DeclaredAddress:

Postcode:Why is this person interested in working with Animals for Therapy?

4

What activities is this person interested in? (Please highlight)

Animal Assisted Activities (range of assisted animal care duties and education activities)Animal Assisted Therapy (Talking therapy/Counselling/CBT/Mindfulness)Social and Therapeutic Horticulture (Gardening, Horticulture Activities)Nature based Activities (range of Nature Art and Bushcraft activities)

How does this link with their current care plan and goals for recovery?

In your opinion how have any past activities and psychological interventions been helpful?

Clinical details

5

Does the client have a Care Programme Approach assessment and care plan? YES/NO

If yes please attach a copy of the care plan

Please give a brief description of the client’s mental health

6

Diagnosis:

Any side effects:

Any further information that you think may be relevant:

Does the client have a history of self-harm or suicidal behaviour? Yes/NoDoes the client have a history of violence or abusive behaviour? Yes/NoDoes the client have any criminal convictions? Yes/NoDoes the client have a history of alcohol or drug misuse? Yes/No

If any of the above applies please detail in the box below

7

Emergency contact details:

Name:

Relationship:

Telephone:

Referrer’s name and signature:

Date: