Embed Size (px)
Citation preview
Email: [email protected]: www.animalsfortherapy.org.uk
Client details – Self ReferralMr/Ms/Miss/Mrs:
Name:
Surname:
Date of birth: Telephone:
Address:
Postcode:
Date of Referral:
Why are you interested in working with Animals for Therapy/Nature For Therapy?
What activities are you interested in? (Please highlight)
Animal Assisted Activities (range of assisted animal care duties and education activities)Animal Assisted Therapy (Talking therapy/Counseling/CBT/Mindfulness)Social and Therapeutic Horticulture (Gardening, Horticulture Activities)Nature based Activities (range of Nature Art and Bushcraft activities)
What services are you already accessing?
How would you describe your mental and physical health?
Referrer Details if relevant (Care Coordinator, GP, Psychiatrist)
Name:
Telephone:
Agency:
Job Title:
AFT/NFT Self Referral Form V1.1
