1 Start 2 Page 2 - Client info 3 Complete Welcome to the referral page for Venture Trust's Outdoor Therapy and Wellbeing Hub services. It's a big step to ask for help and we would like to recognise that it can be scary too. Once you or the person referring you have completed the form below, an intake counsellor will make contact to arrange an initial discussion. This will give us a chance to explain more about the service and for you to tell us a bit about more about yourself. If we all agree that it's the best thing for you, we will then allocate you to a Therapist who you will begin working with. Client Existing Participant Venture Trust Staff - enter name of existing participant here If referring from outside Venture Trust, please enter "Create New" and fill in details below. First Name Last Name Gender - None -FemaleMaleOther Birth Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021 Street Address City Postal Code Phone Number Email Client's medical details Doctors Name Doctors Phone Number Clinic Name and Address Is the client currently prescribed medication? Yes No If yes, please give details of prescribed medication including what it's for, dosage and frequency here. If you are referring someone else, please complete the details below. If you are referring yourself, please leave this section blank and continue to the next page. Referrer First Name Last Name Phone Number Email Referring Organisation Name of Referring Organisation Start to type your organisation name into the field below. Select the correct option when it appears. If your organisation name does not appear, select Create New to enter it. Organization Name Street Address City Postal Code Local Authority - None -Aberdeen CityAberdeenshireAngusArgyll and ButeClackmannanshireDumfries and GallowayDundee CityEast AyrshireEast DunbartonshireEast LothianEast RenfrewshireEdinburgh, City ofFalkirkFifeGlasgow CityHighlandInverclydeMidlothianMorayNa h-Eileanan SiarNorth AyrshireNorth LanarkshireOrkney IslandsPerth and KinrossRenfrewshireScottish BordersShetland IslandsSouth AyrshireSouth LanarkshireStirlingWest DunbartonshireWest Lothian Reasons for Referral Referral date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20192020202120222023 CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Math question * 10 + 5 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.