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.
*

Leicester City Council
Leicestershire County Council
Somewhere else

2. Where did you hear about Green SPark? *

I'm an NCHA customer
My GP or social prescriber referred me
My community reablement worker referred me (this is through Getting Help in the Neighbourhood/Three Conversations)
The Wellbeing Café
Social media
Other (please specify):

3. What is your full name? *

4. What do you prefer to be called?

5. What is your date of birth? *

	DD/MM/YYYY

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? *

Email
Phone call
Text
Post

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?

Yes - I am filling it in for someone else
No - I am filling it in for myself

If you're filling it in for someone else, please tell us your name and a contact number in case we need to reach you: