Dundee
Therapy
Garden
Referrer Details
Client's Details
Name and Preferred Name* :
Contact Number* :
Address* :
Diagnoses :
Allergies & Medications (ie Epipen) :
Do they use any walking aids or wheelchair? Is there anything we can do to make it easier for them to get around?
Date of Birth* :
Name of Their Doctor* :
Address of Their Doctor* :
Contact Number for Their Doctor* :
How Easy Is It For Them to Get Around?
Do they get any other support from health care provider, veterans, or other voluntary organisation? Please provide details :
We are keen for them to come with a support person for initial session(s). Would you or another support person be able to attend? Please provide details.*
Service History
Branch of Service* :
Rank* :
Opertional Deployments* :
Regiment / Sub Unit* :
Years of Service* :
From :
To :
Anything Service Related that We Should Be Aware Of :
Associated Risk Factors
Please tick all applicable
Alcohol Misuse
History of Homelessness
Violence / Aggression
Self Neglect
Substance Misuse
Suicidal Ideation / Intent
Self Harm
History of Offending
Any Other Information
Please address the fields marked in red.
Your Name* :
Address* :
Your Position & Company* :
Contact Number* :
Email Address* :