Referral Form - Little Lost Robot CIC

Use this form to refer to us, any individuals who would benefit from interacting with our programme. Information submitted here is confidential and will only be used to process your referral. Please read our privacy policy HERE. 


Little Lost Robot CIC (Community Interest Company) is a not-for-profit collective of artists working with social practice. We provide a programme of free creative activities that support good mental health and help to develop confidence, in a well-resourced and supportive environment. We work in an unpressured way that nurtures individuals to determine their own creative outcomes by developing practical, creative skills with thoughtful guidance from our professional artists.  


Download this information to share with the person you are referring HERE. 

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Contact details (for person being referred)
Name *
Preferred pronouns
Clear selection
Email  *
Telephone *
Age 
(Restrictions may apply to some activities)
 *
Postcode:
(Some sessions are only applicable to certain geographical areas. If affected Little Lost Robot Referral Staff will advise)
 *
Preferred event / session / course (if any)
List all that apply
Consent for referred person to be contacted directly *
If you are completing this referral on behalf of someone else, please provide your name and contact details along with your relationship to the applicant.
Name
Relationship to person being referred
Email
Telephone
Job role and place of work

Briefly describe what you think your referee would most benefit from, by attending our activities

Briefly tell us about any physical or mental health issues that impact daily life for the person being referred.
Additional information
To help us keep everyone safe and provide an inclusive space, it is useful to ask for some additional information - in which we will seek ways to be mutually inclusive and safe. 
Is there anything we need to know about your referred person, that may put them or others at risk?  Give a brief description. If yes, we may ask for further information and conduct a confidential risk assessment.  
We celebrate diversity and promote equality of opportunity. If you / your referred person has any other issues or experiences that have limited your ability to take part in community activities, please give a brief description here, to enable staff to ensure you are supported to access our programme fully and meaningfully.
Thank you for kindly completing our referral form. All information gathered is confidential. 
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