Green SPark referral form

Please complete this form if you'd like to be contacted by the Green SPark referrals coordinator. They will get in touch with you to explain more about how the service works and to understand what your needs are.

1. Which council area do you live in? Please be aware that only residents of Leicestershire County Council are able to take part in the Green SPark scheme.


2. Where did you hear about Green SPark? *


3. What is your full name? *


4. What do you prefer to be called?


5. What is your date of birth? *


6. What is your address? *


7. What is your phone number?


8. What is your email address?


9. How would you like us to contact you? *


10. Do you have any mobility, support or access needs? *


11. If yes, please give details:


12. How are you normally supported? For example, by family, friends, carers, support workers, etc.


13. Do you have any other health issues we need to be aware of?


14. Please provide the name of someone we can contact in an emergency: *


15. Their relationship to you:


16. Their phone number: *


17. How would you describe your mental health?


18. Are you filling in this form on behalf of someone else?