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Disability Information

Please complete all sections fully to enable us to provide the right support and ensure that you can access sessions safely. All information will be held in confidence.

Disability and Inclusion Information Form

Name
DD slash MM slash YYYY
How would you describe your gender?(Required)

Pronouns are the part of speech used to refer to someone in the third person.

We want to know how to respectfully refer to you!

(Required)
Are you currently a member of Your Trust?(Required)

Emergency Contact Details

Name(Required)

Conditions

Please tick if you suffer from any of the conditions below

Please give details here about all conditions including those ticked above

Other Health Information

Would you need to have medication with you at a session?(Required)
This includes inhalers, GTN spray, Epi Pen, rescue medications for seizures, and regular medications that would have to be given in sessions
If yes, who would be responsible for holding and administering medication?
Have you had hospitalisation or surgery within the last 6 months, or recent illness?(Required)
Do you have any current investigations or are you awaiting test results?(Required)

Other Information Required

Are you a wheelchair user?(Required)
If yes, type of chair?
If yes, preferred transfer style?
Do you use a walking frame or other mobility aid?(Required)
Do you have an assistance dog you will bring to sessions?(Required)
Please note:

We are happy to comply with Equality Act of 2010 in regards to trained and registered service dogs, but we are unable to accommodate emotional support animals or therapy animals. We are happy to comply with Equality Act of 2010 in regards to trained and registered service dogs, but we are unable to accommodate emotional support animals or therapy animals.

What is your preferred communication method?(Required)
Do you have any allergies?(Required)
Will you be attending with a carer, personal assistant or support staff?(Required)
PLEASE NOTE – unless a session specifically states otherwise, we are unable to offer any help with personal care.
Information required to access specific sessions such as cycling, rebound therapy, or any other session using equipment with height or weight restrictions.

Statement

DD slash MM slash YYYY

If you are completing this form as a referral, please give your details