Make a Referral

For children, young people and adults being referred to The Wild Mane Project.
This form is intentionally brief to support busy professionals. Further information can be gathered separately if needed.

Referrer Details

Referrers Name

Role / Job Title

Organisation / School / Practice

Email

Phone

Person Being Referred

Referral Type

Full Name

Date of Birth

Day

Month

Year

Address

Phone Number

Email

Main Contact Name

If the referral is for a child/ young person, please provide parent/carer details

Brief Reason for Referral

A short summary helps us understand the participant’s current circumstances.

Safeguarding

This information will be treated confidentially and stored in line with Wild Mane’s Safeguarding and Data Protection policies.

Consent & Agreement

Single choice

I confirm that the information provided is accurate to the best of my knowledge.

Funding & Fees

By submitting this referral, the referring organisation confirms that it is responsible for the full cost of the programme, unless alternative funding has been agreed in writing in advance.