First name (required)

Surname (required)

Postcode

Email (required)

Telephone

Emergency contact number

Please answer all the questions below. The following information will be helpful for the facilitators and help in planning around your needs.

The information collected on this intake form is confidential and is reviewed only by our team to help us create a safe and supportive environment.

Declaration: I confirm the above information is correct. I understand it is my responsibility to:

• If relevant, check with my doctor if I have difficulties about my ability to participate in the course

All personal information will not be shared or sold and will be for the sole use of Craigsfarm Community Hub. I give permission to Craigsfarm Community Hub to use photographs obtained during classes, workshops and events to use as part of a public display which may include Craigsfarm Community Hub website and other print publications.

Data Protection: Craigsfarm Community Hub complies with data protection law in the UK and laws in other countries that meet internationally accepted standards. You have the right to ask for a copy of the information we hold on you, and the right to ask us to correct any inaccuracies in that information. If you have concerns about how we have used your personal information, you also have the right to complain to a privacy regulator. For detailed information, contact us on info@craigsfarm.org.uk for a copy of our Privacy Policy.

Print name (required)

Signed (required)

Date (required)

I would like to receive information and updates on Craigsfarm Community wellbeing + resilience programme activities and Craigsfarm events

Please let us know how you heard about this service:

—Please choose an option—Bridge CounsellingBridge Financial WellbeingMy GPCommunity Psychiatric Nurse (CPN)NHS Boghall HubNHS Wellbeing HubNHS Mental Health NurseNHS St John's HospitalWest Lothian WellbeingOther community servicePoster or leafletKonect MagazineA friendA family memberOtherI attended a course beforeFacebookInstagramGoogle Search

Thank you for completing this form

Δ