Myplace and The Bay referral form

Katrina Martin / 2020VISION

Referral form

Refer someone else onto a Myplace or The Bay wellbeing programme

Please use this form to refer someone else onto a Myplace or The Bay wellbeing programme. If you have any questions, please don't hesitate to get in touch with a member of our team.

If you're looking to refer yourself onto a wellbeing programme, please use our self-referral form instead.

Self-referral form

To find out more about the different sessions we offer, scroll to the 'About our sessions' section on the Myplace webpage.

T: 01772 872007 or 07738 102274 (mobile)
E: myplace@lancswt.org.uk or thebay-enquiries@lancswt.org.uk

Details of person being referred

Participant first name

Participant last name

Participant Date of Birth (DD/MM/YYYY)

Participant address

Participant town

Participant postcode

Participant contact email

Participant contact number

How did they hear about us?

If you selected other, please let us know how they heard about our service

Details of referrer

Referrer first name

Referrer last name

Referrer position/team

Referrer organisation name

Referrer organisation address

Referrer contact email

Referrer contact number

Has the individual consented to this referral?

Yes

How would they like to get involved?

There are a number of ways you can get involved with us. Please choose the option you would be most interested in from the list below.

What do they hope to gain from attending nature and wellbeing sessions?

Is being with a group of six people okay?

Yes

Details of allergies, physical or mental health concerns, learning disabilities or other needs

Is there anything else you may wish to tell us about?

What is their current occupation?

Unspent criminal convictions in accordance with the Rehabilitation of Offenders Act 1974 (exceptions) order 1975 &/or (NI) 1979

Referral next steps - who should we contact?

Referrer

Individual

Are they under 18?

Yes

Please tick box to indicate.

If they are under 18, please tick this box to indicate you have received parent/guardian consent to get in touch with us

Parent/Guardian full name (if applicable)

Parent/Guardian contact number (if applicable)

Parent/Guardian contact email (if applicable)

We'd love to keep you updated with Lancashire Wildlife Trust news, activities and appeals. Are you are happy to hear from us in this way?

Yes

By signing up to our mailing list you are opting in to receive emails about events, local wildlife, campaigns, appeals and our further work We respect your privacy and will never sell your details, and you may change your preferences at any time. For more information about how we use your data please click here, and if you have any questions, please call 01772 324129 or email membership@lancswt.org.uk.

Please be aware that this information will be stored securely and retained at least until 31 December 2026, in compliance with the Data Protection Act 2018. For further information please click here to view our Privacy Statement or call us on 01772 324129.

Referral form