Adult Referral Form
(for professionals)

This form is to be completed by a professional referring an adult participant. It can be completed by their employer also.

Referrer Details

Referrers Name

Role / Job Title

Organisation / School / Practice

Email

Phone

Best time to contact you

Participant’s Details

Participant's First name

Participant's Last name

Name Known by

Date of Birth

Day

Month

Year

Address

Phone Number

Email

Emergency Contact Name

Emergency Contact Number

Background Information

Does the Participant attend college or university?

Does the Participant have an EHCP or identified SEND?

Yes

No

If yes, please outline needs

Do they have any Mental Health conditions that we need to be aware of?

Do we need to be aware of any agencies involved (e.g., GP, Social Care, Mental Health Team)?

Reasons for Referral

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

Please summarise the main reasons you are referring this participant to Wild Mane.

Brief Summary

Safeguarding

Any safeguarding concerns we should be aware of?

Risk and Safety I understand that Wild Mane relies on referrers to provide accurate and complete information to ensure appropriate support and risk management.

I confirm that I have disclosed any information relevant to the safety or wellbeing of the participant, other group members, staff, or animals. This includes any known risk-taking behaviour, aggression, safeguarding concerns, or incidents that could affect participation or safety at Wild Mane Wilderness & Equine Therapeutic Centre.

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 participant is aware of and consents to this referral.

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.