OCN course referral form

July course is now full – waiting list places only.

Please note, this form is for agency referrals to our Practical Organic Gardening OCN Course for Lewisham residents who are 18 years and over and who are experiencing mental health difficulties and want to come and learn in a supportive environment.

The contents of this form are treated as confidential by our organisation. Some of the data on this form will be converted to data stored on a computer retrieval system in accordance with the General Data Protection Regulations and Data Protection Action 2018.

NEXT COURSE STARTS: JULY 2023

Practical Organic Gardening OCN Course - for referrers

For referrals to our free Practical Organic Gardening OCN Course. Learners attend every Thursday for 2.5 hours at Sydenham Garden.

A. Personal Details

Please complete client/patient's details below:

My client is experiencing at least one of the following:(Required)

Mental health challenges

Learning disability/difficulty

Physical health condition(s)

Unemployed and in receipt of benefits

First name(s)(Required)

Surname(Required)

Date of Birth(Required)

PLEASE NOTE THIS COURSE IS FOR PEOPLE AGED 18 AND OVER.

Address(Required)

PLEASE NOTE THIS COURSE IS ONLY FOR RESIDENTS OF THE LONDON BOROUGH OF LEWISHAM

Postcode(Required)

Main contact number(Required)

This is the preferred contact number - it can be a mobile or landline

Additional contact number

It is very helpful for us to be able to communicate by email, if possible.

B. Referrer

Referral source(Required)

Name of referrer(Required)

Role(Required)

Agency & Team(Required)

Address including postcode(Required)

Contact number(Required)

Email(Required)

Brief summary of any support you have provided(Required)

Referral supporting information provided

Assessment

Care plan

Discharge letter

Risk Assessment

Safety plan

Other

Please attach supporting information using the form upload function at the end of this form.

Will you/your team continue to work with the client for at least the next month?(Required)

Yes

C. Wellbeing

Please describe how your client's health and wellbeing is currently affecting them.(Required)

Does your client have a mental health diagnosis?(Required)

Yes (please give details below)

Details of mental health diagnosis

Does your client have any access requirements they would like us to be aware of?

(e.g. seated activities required).

Are there any physical health concerns that we should be aware of? E.g. insulin dependent, diabetes, epilepsy, heart condition, back pain, medication side effects etc.(Required)

Yes (Please give details below)

Details of physical health concerns

D. Risk

Risk to others. Please note: we are only able to accept referrals when risk to others is currently assessed as low. Does your client have a history/conviction for violence, aggression or risk to others?(Required)

Yes - within past two years

Yes - over two years ago

If yes, please give further information below.

Details of history of risk to others including dates (e.g. convictions for violence, aggression)(Required)

Please upload current risk assessment at end of this form.

Risk to self. Does your client have a history of self-harm? Please include details of self-neglect, suicide attempts, eating disorders.(Required)

Yes - current

Yes - within past two years

Yes - over two years ago

If there is a current risk, please upload a safety plan at end of this form.

Further details of risk to self, including dates (current or historic)(Required)

Does your client have current or history of drug and alcohol use?(Required)

Yes - current

Yes - historic - currently abstinent

Please note that we ask that people do not attend sessions whilst under the influence of alcohol or illegal drugs.

Are they currently engaged with any drug and alcohol services in the community?(Required)

E. OCN course and support needs - IN APPLICANT'S OWN WORDS

Are you a resident of the London Borough of Lewisham? We have free places available for Lewisham residents only. (Proof of address may be required - e.g. recent; council tax bill, utility bill, driving licence, benefits letter, NHS letter).(Required)

Yes, I am currently a Lewisham resident

No, I am not currently a Lewisham resident

Have you attended a group at Sydenham Garden in the past? Which group(s)?(Required)

Not previously attended

African & Caribbean

Art & Craft

Garden at Wynell Rd

Growing Lives at De Frene Rd

Art Club

Bee Club

Walking Group

Other

Please note that we are not able to consider referrals from people who have already completed two or more project placements with us.

Please note that this course is in 'Practical Organic Gardening', with an emphasis on training participants for further qualifications and work in the industry. Please use this space to share two or three sentences which will tell us why you would like to join the course and what kinds of horticultural roles you might be interested in doing in the future. (e.g. community garden worker, landscape gardener, park maintenance worker, garden designer, garden centre worker, food grower).(Required)

Please use this space to tell us about any experience you have which you feel might be relevant to the course. (e.g volunteering at a community garden, helping a friend on their allotment, growing vegetables on your balcony).(Required)

Do you have any barriers to learning or additional support needs that it would be good for us to know about? (e.g. dyslexia, support with writing required, visual learner). How could we best support you to learn if you were offered a placement?(Required)

F: Diversity Monitoring

As part of our monitoring processes we ask for your co-operation in completing the questions in this section. Sydenham Garden is committed to the principles of fairness, consistency, and equality of opportunity. No person will be discriminated against because of their age, disability or ability, ethnicity, gender or gender identity, religion or belief and / or sexual orientation, or if you prefer not to complete this section. The information you enter on this form will be used for monitoring purposes only and all reporting will be anonymous. Data is kept securely in line with current data protection legislation.

Consent(Required)

Yes

Please tick this box to confirm your client's consent for Sydenham Garden to store and process the information given below to report anonymously on demographic and diversity data for the organisation. Please ask your client to answer the following questions:

Gender(Required)

Female

Male

Transgender

Non-binary

Other

Prefer not to say

Sexuality(Required)

Heterosexual (straight)

Bisexual

Gay

Lesbian

Asexual

Other

Prefer not to say

Ethnicity(Required)

Religion(Required)

Disabilities & Health Conditions(Required)

Are you registered disabled with the local authority?(Required)

Yes

Not sure

Prefer not to say

Please upload any documents mentioned in section B.

Drop files here or

Accepted file types: jpg, png, pdf, doc, xls, bmp, Max. file size: 256 MB.

Signature of referrer(Required)

Date(Required)

Please tick to confirm that your client consents to Sydenham Garden processing their personal data(Required)

Yes

Transparency notice to be shown to your client: Sydenham Garden (SG) records certain information about you. This information is overseen by SG’s Data Controller. The Data Controller can be contacted at the Resource Centre Office. We record your name, address and telephone details as well as details of an emergency contact. We also record your mental health diagnosis and important information (such as a risk assessment) sent to us by the health professional who referred you, in order to give you the safest care possible. The legal basis for holding this information is called ‘legitimate interest’. We will hold your records for a further 6 years after you complete your time as a co-worker with us, in line with NHS policy. We will never pass your information onto an external individual or organisation without seeking your consent first. While reports on the effectiveness of the charity’s work are sent to funders including Lewisham CCG and Lewisham Council, it is not possible to identify individuals from these reports. You have the following rights relating to the information that we hold about you: -A right to see the information we hold on you (access). SG will agree to your request as soon as practicably possible and not later than 1 month from the date of the request. -A right to request any errors in your information are corrected (rectification). SG will agree to your request as soon as practicably possible and not later than 1 month from the date of the request. -A right to request your information is erased from Sydenham Garden’s records (erasure). If there is no good reason for SG to hold your information, SG will agree to your request to erase the information it holds on you. However, while you are a co-worker, there will be a continuing good reason to hold the information to help us to provide you with the best care possible. -A right to complain to the Data Controller using the SG Complaints Procedure. If you feel we have not responded correctly to your request please follow the SG Complaints Procedure. Should you not be satisfied after using our complaints procedure you have a right to complain to the Information Commissioners Office via: https://ico.org.uk/concerns/ or by the Helpline on 0303 123 1113.

Thanks for completing this referral. Please click on 'Submit' button below.

Comments

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OCN course referral form

Practical Organic Gardening OCN Course - for referrers

A. Personal Details

B. Referrer

C. Wellbeing

D. Risk

E. OCN course and support needs - IN APPLICANT'S OWN WORDS

F: Diversity Monitoring

Thanks for completing this referral. Please click on 'Submit' button below.

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