Adults Art Booking/ Referral Form

First name (Attendee)

Last name

How old are you?

Phone

What is your ethnicity?

Choice of interest, subject to availability

Group

1-2-1

Virtual

How many will you be?

How will you attend?

Where did you hear about us?

Are you happy for us to retain your information to contact you about our services?

JKA occasionally takes photos and audio/video recordings of attendees for archive purposes, training and use in promotional material (inc. internet). Do you give your consent to us using images of you for these purposes in line with our policies?

Yes

We would like to send you information about JKA activities and other opportunities and events we offer. This may include art events by Joyti Kaur. Your details will not be passed to any other organisation. Whatsapp group, mailing list opt in?

Yes

Please share details of your family. Name of your family member/s. Their relationship to you (2 contacts are preferable) Their contact details (if different to yours), address, contact number, Email address (This will be used as an emergency contact)

Do you have any disabilities we should know about?

Is this referral/ booking made for yourself or on behalf of someone else, If for someone else, please provide your full name, contact information and your relationship to the attendee, confirming they are aware of this referral

We currently operate on a timetabled schedule of once a month, how often would you require our service, on which preferred day and time. Preferences are dependent on availability

Tell us about the support you get and services you use. Where are you currently living and what kind of support do you receive? What other services do you use? Who are the key professionals involved in your life? Any other relevant information

Tell us about the support you need from us What type of support do you need from us? How often do you need this support, on which days and at what times? What are you hoping to gain from using our service or receiving our support?

How will the service be funded? I.e I will pay for it myself with my own money and/or using my benefits. I will pay for it using a Council funded Direct Payment. I will pay for it using a Personal Health Budget. The Council/other public body.

Who is contracting the service and who will make decisions about the care that is required? Individual Family (or related third party )

Please attach the following if applicable Current risk assessment Support or care plan Care assessment

Are there things about your faith or religion that it would help us to know about?

How do you like to communicate? e.g. by talking, signing, showing, communication device or by other means? Do you have any communication aids? Would you attend sessions with a support worker/ carer?

Do you use any equipment to get about such as a wheelchair, walking frame, rails or a hoist? Are there any risks to you or others linked to you moving or getting about? What do you and people who support you do to manage these risks?

Do you take/use any prescribed medication? Are you allergic to anything – including any medication? Please share details of your doctor and any other medical professionals you consult.

How do you show you are: • Angry or upset • Frightened • Worried or anxious • Bored • Excited • Happy

What could we do or say to support you to communicate how you feel and to manage your feelings? Our sessions whilst supportive of each individual, we want to ensure all individuals are comfortable in the group adhering to our behavioural policy

Care Manager contact details if applicable (full name, address, phone number, email address)

Social worker contact details if applicable (full name, address, phone number, email address)

Support worker/ carer contact details (full name, address, phone number, email address)

GP, Consultant, CPN contact details (full name, address, phone number, email address)

Your NHS Number

I give permission for my Paid Carer to share relevant information with other organisations/ individuals where it is beneficial/necessary for my health or welfare.

The Who Am I Section! Tell us about you, How people who know me would describe me: What people like and admire about me: What I care about What I am good at: Things in my past that are important for people to know

JOYTI KAUR ART "Making Art Accessible To All"

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Booking Form

JKA Children & Young People

Joyti Kaur Art School Outreach

Adults Art Booking/ Referral Form