Referral Form

September – December 2023

Participant Section

To be filled out by workshop attendee. All session start week beginning 4th September.

Title *

Mr, Mrs, Miss, Ms etc.

Pronouns

Name *

First

Last

Email *

Phone *

Date of Birth *

day/month/year

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Which group would you like to try? *

Monday 12pm – 2pm Embroidery (Starts 9th October)
Tuesday 12pm – 2pm Drama (Nemo Arts Studio)
Tuesday 2:30 – 4:30 Physical Theatre (Nemo Arts Studio)
Wednesday 2:30pm-4:30pm Choir (Nemo Arts Studio)
Thursday 2:30 – 4:30 Drama (Nemo Arts Studio)
Friday 2:30pm – 4:30pm Creative Writing (Nemo Arts Studio)
Saturday 12pm – 2pm Visual Art (In person and on Zoom) Nemo Arts Studio

Support Needs

Please tell us if there is anything you think we should know to help you participate, for example leaving space at the table for wheelchair access, large print or being closer to the tutor to hear better.

Referring Agency

To be filled out by referrer, if you are self referring please provide emergency contact details.

Name

First

Last

Phone

Role

for instance O.T, CPN, CMHT, Social Worker

Does the person have a care plan and does this activity contribute towards it?

Please describe what outcomes are expected for the participant during their attendance at Nemo Arts

Would you prefer to attend workshops at our studio or online? *

Online
At our studio (in-person)

Phone