Referrals

To refer someone to the Ocean Therapy program, confirm they meet eligibility requirements, gather their contact and relevant background information, and enter the form below. Submit it via the designated method, then notify the individual or their guardian about next steps and any preparations needed before their first session.

First name (of the person requiring support):

Last name (of the person requiring support):

Gender

Male

Female

Prefer Not to Say

Date of Birth

Day

Month

Year

Address

Post Code

Contact Telephone Number

Email

Please Provide Your Name, Organisation, Contact Address and Phone Number:

Is The Person Aware of Being Referred?

Yes

No

Please Provide Details of GP (including address and telephone number)

Please Indicate Which of the Following Options Best Describes Their Current Status:

If the person is involved in the criminal justice system, please complete the below section:

Licence Expiry Date

Day

Month

Year

Other Information

How do you think Surf Therapy CIC can help? Please use the space below to include any information that you think will be useful (for example, diagnosis, symptoms, medication). Please be as detailed as possible. This information helps us on how to support

Who else is involved in the care of the person you are referring (e.g. GP, Probation)?

Do you have any specific requirements (dietary, mobility)?

If you or the person you are referring have any questions regarding accessing this service, please use the space below to detail them:

Accessing Surf Therapy CIC Support Services:

Our service is available to anyone in the UK, but all activities are carried out in the City and County of Swansea. Our services are funded by a number of different sources. Our regular surfing and Ocean Therapy activities are provided to the individual free of charge. We do occasionally provide surf and Ocean Therapy sessions for non-referred groups or agencies at a cost. Any funds gained from these paid sessions is used to fund the free Ocean Therapy and surf sessions.

We provide:

Initial Assessment (face to face)
Access to weekly Ocean Therapy and surf sessions
Use of our equipment when taking part in activities
Sign-posting service

Please sign below to confirm the following:

The information contained within the referral form is accurate.
You give permission for Surf Therapy CIC to contact you to discuss your referral.

Signature

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Referrals

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