Inclusion Project Community Joining Form

1
Details of the person filling in this form* This field is required.Who are you?
Full Name
Relationship to the Participant, if you are not the Participant.
Full Name of the person we will be corresponding with (if different than above) and relationship (if different than above)
Email Address (this is the email we will correspond with in regards to this referral)
Telephone Number (this is the number we will correspond with in regards to this referral)
2
What is your Name?* This field is required.The person filling in this form
First Name
Last Name
3
Are you enquiring for yourself or on behalf of someone else?* This field is required.
For YourselfFor Someone Else
4
What is their Name?* This field is required.
First Name
Last Name
5
What is your relationship to them?* This field is required.
6
Contact Details of the Person you want us to contact about this referral * This field is required.So we can contact regarding this referral to arrange the next steps
Please enter your email
Please enter your phone
7
Contact Details of the Person you want us to contact about this referral * This field is required.So we can make contact regarding this referral to arrange the next steps
Please enter your email
Please enter your phone
8
Which Area of The Inclusion Project would you like to be referred to?* This field is required.
West Hertfordshire - Watford, Hemel Hempstead, Berkhampstead, Tring etc.
Hertfordshire - all excluding West Hertfordshire
South Bedfordshire - Luton, Dunstable, etc.
North London - Barnet, Enfield, etc.
North West Bedfordshire - Bedford, Milton Keynes, etc.
North West London - Harrow, Brent, Wembley, etc.
West London
Cambridge
9
Details of the person wishing to access The Inclusion Project.* This field is required.Who is the Participant? ('Participant' is the name that we use for the people that use our service).
Full Name
Email Address
Telephone Number
10
Participant's NameThis is needed in order to include the participant's name in the title of the PDF file
11
Address of the Participant* This field is required.We need to know this to inform which location of The Inclusion Project the Participant would be able to access.
Street Address
Street Address Line 2
City
County
Post Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
Will the Participant in question be over the age of 18 years old when attending their first session with The Inclusion Project?* This field is required.The Inclusion Project is unable to support anybody under the age of 18 years old.
YESNO
13
Further information for your Referral* This field is required.We can discuss these points in our initial phone call. This is just to gather further information.
YesNo
YesNo
YesNo
YesNo
Can the Participant be safely supported in the community?
Can the Participant be supported at a 3:1 ratio? (3 Participants : 1 Staff Member)
Can the Participant be transported in an ordinary road car?
Is there funding in place to pay for our services?
Can the Participant be safely supported in the community?
YesNo
YesNo
YesNo
YesNo
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14
What type of session is the Participant interested in attending/finding out more about?
Day Sessions (7 hour sessions)
Evening Sessions (4 hour sessions)
Day and Evening Sessions
15
Which sessions are you interested in?* This field is required.
Monday Day Session (7 hours)
Tuesday Day Session (7 hours)
Wednesday Day Session (7 hours)
Thursday Day Session (7 hours)
Friday Day Session (7 hours)
Saturday Day Session (7 hours)
Sunday Day Session (7 hours)
Weekday Evening Sessions (4 hours)
Weekend Evening Sessions (4 hours)
One-Off Sessions
16
Any other information you would like to share at this point?We will gather a lot more information at the initial 'Meet and Greet' assessment, this form is just a short introduction. Thank you.
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