Mamma's scrapbook: A Sensory Storytelling Project - Whitehawk self referral form 
Mamma's scrapbook Whitehawk will be starting on 11th November

Your information will be stored securely and will be kept confidential

Please read accompanying information to ensure you know what the group entails. 

Please note your information will be stored securely and will be kept confidential

Please read accompanying information to ensure you know what the group entails. 

If you have any questions and for further information please contact caroline@mycelianetwork.co.uk 
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Mamma's Scrapbook: A Sensory Storytelling Project 
Title 
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First Name 
Last Name 
Address and postcode
Date of birth 
MM
/
DD
/
YYYY
Gender/preferred pronouns
Email address
Mobile number
Emergency Contact - Name,  relationship and mob number of person to be contacted in 
Main reason for self-referral 

Are there any health conditions that could affect ability to participate in physical outdoor activities? e.g. allergies, asthma, diabetes, heart problems, high or low blood pressure, sensitivity to sunlight or other physical limitations. 

Is any medication being taken on a regular basis?

We ask this question so we know how to support you safely. 

Is there any history of difficulties with emotional dysregulation, drug/alcohol use or any other issues that may require additional support – particularly any episodes within the last 6 months? 

We ask this question so we know how to support you safely and put in any additional support you may need. 

We need to know about your ability to stay safe during the groups. We welcome mothers who have experienced mental health conditions. Please let us know if there are any issues or risk factors that could affect your ability to participate in an outdoor group, in nature connection work or in creative collaboration and ability to keep yourself safe in this environment. 

Are you comfortable using public transport? Or do you have own transport? 
This is a drop group, but we hope a core group may attend most or all sessions. Do you think you will attend  all or most of the 6 sessions? 
Is there any additional information you feel will be useful? 

Please let us know in advance of any adjustments you may need to access the project, including communication support or support with accessing the site. 

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