The attached form is to refer a person to the services provided by Wild Minds Nature Connection CIC. Once you have filled out the below details and submitted the form, we will make contact with the referred person within 5 working days and explain to them about what we do, our services and sessions. You can self refer to our sessions, you can do this by completing the same form below but filling in your own details. If you are filling in the form by hand please fill it out and email a copy to [email protected].

Email *

First Name

Last Name

Date of birth

Which Gender do they associate with

Address

Street Address

City

State

Country

Postal Code

Phone *

What is the best time/day to contact the person being referred?

Current employment Status

Does the person being referred currently live with any of the following conditions?

If you have ticked any of the conditions listed above, please can we ask that you provide more details below, so we are best able to meet their needs (what the conditions are, how they affect the person, how long they have been living with the condition/s)

Which activities/sessions do you think the person being referred would benefit from?

Please provide the name of the person completing this form (if completing on behalf of someone else)

Please provide your job role, locality and contact details.

Is there anything else you think we need to know?

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.