Referral form for AGNI candle making workshop - AGNI Manchester CIC: handmade ceramic meditation candles and mindful gifts

Agency name (required)

Worker name(required)

Client details

Client name(required)

Email(required)

Phone(required)

Date of birth(required)

Address(required)

Postcode(required)

Reason for application(required)

Is your client currently experiencing any mental health issues?(required) Yes

Has your client experienced any mental health issues in the past?(required) Yes

Any relevant medical details

Does the person currently present any current risk of harm to themselves or others?(required) Yes

What is your clients ethnic group? Choose one option that best describes your ethnic group or background(required) White

Mixed/ multiple ethnic groups

Asian/ Asian British

Black/ African/ Caribbean/ Black British

Chinese

Arab

Other ethnic group

Prefer not to say

Do they consider themselves to have a disability?(required) Yes

Prefer not to say

Please let us know if your client requires any adjustments to take part in the workshop:

Confidentiality & Data Protection
AGNI Manchester CIC collects some personal information about the people using our services, including their date of birth, gender, area of residence, employment status and ethnicity. We do not pass any personal information on to any other organisation.

The information collected on the number of service users, employment status, the workshops they attend, and the outcomes they achieve is used to:

monitor how effective AGNIs workshops and courses are
support the improvement of outcomes for service users
help plan and develop services that best meet local needs
produce statistics to support reports and grant applications
AGNI never publish any information that could be used to directly identify individual users AGNIs services.

your information is kept confidentially within AGNI Manchester, and is only accessible by AGNI Manchester staff.
the only circumstances that we would need to break your confidentiality would be if we felt there was an immediate risk to yourself or others. We would usually try to contact you prior to this in the hope of resolving the situation without having to breach your confidentiality.
you can request to see any information held concerning your engagement with AGNI Manchester.

Consent agreement(required) I have been made aware about the confidentiality policy (above)

(required) I agree to my details being stored and processed confidentially and securely in line with the data protection act.

(required) I agree to share my email address with the site owner and Mailchimp to receive updates about our free candle making workshops from the site owner. Use the unsubscribe link in those emails to opt out at any time.

Client details

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