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The Bay wellbeing programme

Refer yourself or someone else

The Bay wellbeing programme referral form

Please use this form to refer onto the The Bay programme. If you have any questions, please don't hesitate to get in touch with The Bay programme's Nature & Wellbeing Officer, Jessica Mordain. You can contact Jessica by email at jessicam@cumbriawildlifetrust.org.uk or telephone 07717 019691

Are you completing this form on behalf of someone else (including a parent/guardian)?

Your details

Please include first line, town and county.
There are a number of ways you can get involved with us. Please choose the option you would be most interested in from the list below.

Details of person being referred

Please include first line, town and county.

Details of referrer

Has the individual consented to this referral?
There are a number of ways they can get involved with us. Please choose the option they would be most interested in from the list below.
Is being with a group of six people okay?

Known safeguarding issues

Self-neglect Self-harrm Suicide attempt Drug/alcohol use Isolation
Physical Financial Sexual Other
Is there potential for violent or aggressive behaviour? Are there any concerns regarding safety to work alone? Are there any concerns regarding safety to work alone in a group?
Theft Damage Other
What is their current occupation?
What is your current occupation?

Equal opportunities

In accordance with Cumbria Wildlife Trust’s policy on equal opportunities, we will provide equal opportunities to any participant and will not discriminate either directly or indirectly on the grounds of race, colour, ethnic origin, nationality, national origin, sex, sexual orientation, religion or belief, marital status, civil partnership, age, gender reassignment or disability.

We would therefore be grateful if you could complete the questions on this form. All information will be treated in confidence and is collected for project monitoring purposes only.
Gender
Ethnicity
Disability and impairment
Do you identify yourself as a deaf or disabled person?
Disability and impairment
Do they identify themselves as a deaf or disabled person?
Sexuality
Referral next steps - who should we contact?
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