Mixing music and social media, changing lives

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Please enter your details into the form below, scroll down through the questions and press "submit" to send.

Fields marked with a * are required (a full list of these required fields can be found at the bottom of the page)

Data security:
The Views system where this data is hosted "live" uses Rackspace, a UK based virtual hosting company.
The service provider is used by a number of government agencies
and provides firewalls and monitors access to the cloud servers used.
The companys centres are accredited to ISO27001 standards.


Identity (of person being referred)

First name*:

Last name*:


Date of birth:


Student's landline:


Student's mobile:


Student's email:


Address1*:


Address2:


Town*:


Post code*: Please supply VALID post code in format: sw17 6fy or sw176fy


Gender

Gender*:

Male

Female

Other

Blog

Does the participant consent to publishing their blog?*:
A common feature of Noise Solution's work is using audio/video to capture work done. This is incorporated into a blog which is published on the internet
making it available for learners to use as a portfolio of work. This work will be password protected unless the participant requests not:


Referral Information

Referral Agency/Organisation*:


Key worker's name*:


Key worker's phone number (mobile or landline)*: Please enter numbers only ie 0207389745


Key worker's email:


Is there music making the student is particularly interested in?


[If yes] which aspects interest them?


What does the referring agency hope to achieve with this referral?


What does the student hope to gain from this referral?


What are the student's social and behavioral strengths?

What are the student's social and behavioral weaknesses?

Does the client have a history of violence or unpredictable behaviour? Are there likely 'triggers' that will affect the client's behaviour?*


[If yes] What are the 'triggers'?

Are there any days that the learner is not available, or anything Noise Solution should be aware of regarding scheduling that might interfere?


Does the client have a history of making allegations against support workers or other professionals?

Please indicate how many sessions you are applying for funding for or if you know how many sessions you want to book then please state the number here. If you are unsure please contact us to discuss:

Who do we invoice, and contact information please?*


Are you aware that if a booking is cancelled less than 24 hours before, the session will still be charged?*


Further information?


Status:


Description of participant's status (i.e how many months out of EET):


Disability

Does the participant have a disability?


[If yes] what are the disabilities?


Medical Conditions

Does the participant have any medical conditions?


[If yes] what are the medical conditions?


Emergency Contact

Emergency contact Name:


Emergency contact - relationship to student


Emergency contact Number (please enter digits only):


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