Apply to join a Pathways to Wellbeing Group

Pathways Application Form All information you give will be treated confidentially, read only by the Pathways to Wellbeing Manager, and will not be shared with any other organisations.
Name *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Telephone Number *
Email
Date of Birth
Service Referring Person
Emergency Contact (family member or friend) Please include a name and contact number *

Are you currently being supported by any services?
Yes
Have you been referred or signposted to the group by a mental health/ support worker/ social prescriber?
Yes
Name of support / mental health worker
Telephone Number
Email
Permission to contact this person in an emergency
Yes
Which group would you like to join: *
Gardener's Lodge Art GroupIMAGE Art GroupDiscover Museums – Mentored Volunteering Course
Extra Support
We have a responsibility to provide a safe and supportive environment for all group members. Is there anything we should know that would help us to support you? (e.g. disabilities, travel difficulties, concerns you’d like to share before you start).
More information
Is there anything else we should know that would affect your participation in this group (e.g. anxiety, depression, PTSD, panic attacks ) This will be treated as confidential.