Fire & Peace Recovery Referral Form

Welcome to Fire & Peace Recovery's referral form! 

If you or someone you know could benefit from our transformative programs, we invite you to complete this simple referral form. Our nature-based experiences are designed to improve mental and emotional well-being, especially for those who may have faced adverse childhood experiences, substance abuse, mental health challenges, trauma or loss.

Join us in making a positive impact by referring someone who could benefit from the healing power of nature. Thank you for being a part of our mission to promote well-being and resilience.

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If you are making a referral on behalf of someone else... 
Please leave your details bellow so that we know who has filled out this form on behalf of the referred individual. Please skip the next two questions if you are referring yourself.
Your Name/Your Organisations Name
Your Contact Details/Organisations Contact Details - Address, email, phone.
Referrer Information
This section is about the person being referred. If you are referring yourself please answer the following questions about you, if you are referring someone else please give their details to the best of your knowledge.
First Name - of the person being referred *
Last Name - of the person being referred  *
Date of birth - dd/mm/yyyy *
Preferred Pronouns
Email - Please provide the best email contact to discuss this referral through *
Phone Number - Please provide the best phone number to discuss this referral on *
Preferred method of contact *
Required
Address
Postcode *
Have you participated in a Fire & Peace Recovery programme before?  *
Which of the following best describes your current situation?  *
Have you experienced any of the following? *
Required
Substance dependence details - if you are currently recovering from substance dependency, please provide us with more details on your recovery plan. Please confirm that you are not currently using illicit drugs and inform us of any methadone prescriptions you are actively receiving. Fire & Peace supports people recovering from addiction whilst on a methadone reduction plan.
What do you want to change in your life? - Fire & Peace Recovery programmes are about making positive changes. Please tell us what you'd like to improve on or change in your life *
What would you like to take part in?  *
Required
Is there anything else you would like to tell us?
Help and support from agencies (other than referring agency) - If you receive help or support from agencies, community mental health nurses, social workers, etc. Please provide us with more details. 
Diversity Monitoring
Fire & Peace Recovery is committed to ensuring that the diversity of our beneficiaries, volunteers, staff, and Board of Trustees, represents the diversity of the local communities we aim to serve. The information you provide on this monitoring form is optional and will allow us to evaluate if we are living up to this commitment. If at any point you wish to have information removed from our databases please inform a member of staff.
Gender - Which of the following best describes your gender
Clear selection
Ethnic Origin
Religion
Do you consider yourself to have a disability? - The 2010 Equality Act defines a person with a disability as someone who has ‘a physical or mental impairment which has a ‘substantial’ and ‘long-term’ adverse effect on his/her ability to carry out normal day to day activities.’ 
Clear selection
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