Nature for Health Referral Form 
Please fill out the following form to refer yourself or someone else onto the Nature for Health programme. The service is free for Manchester residents that are struggling with their health and wellbeing. Once we have this information we will be in touch to discuss activities that you or they can take part in.
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First name  *
Surname *
Date of birth *
MM
/
DD
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YYYY
Gender *
Ethnicity *
Telephone *
Email *
Where did you hear about Nature for Health? *
Postcode  *
Employment status *
Name/ role of person making referral (write N/A if self-referring)  *
Referrer's telephone *
Referrer's email  *
Please list any relevant information about the person being referred/self-referred that we should know
What areas do you want support in?
Is there any other information/ risk we should be aware of? *
If yes, please give details
Preferred location for activities
Consent gained to make referral? *
Consent for Sow the City to contact via phone/ email? *
Submit
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