Contact Us | aebal Leisure

Contact Details - Person making the referral

Social care team or organisation (if applicable)

Contact email

Contact phone number

Contact Details - Person interested in joining aebal

Please enter the full name of person interested in joining and/or Parent or Carer's full name and relationship to the person

New referral phone number / Alternative contact number

Please enter the same contact number as above if needed. The form requires something to be entered here

Address

DOB

Month

Day

Year

New referral contact email / Alternative email

If different to above email

Please tell us a bit about your background, needs, disability and personality

Please include as much as you feel comfortable disclosing in this form. Any potentially sensitive information relevant to the support can be discussed in person at the home visit.

Please let us know some of the reasons you are looking to join aebal. Please select as many as you like!

I would like to make new friends

I lack confidence going out in the community

I am struggling with depression and anxiety

I want to try new activities

I am isolated at home due to my support needs

I want to learn some independent living skills out in the community

I would like to improve my physical health and well-being

My support needs prevent me from safely accessing the community

Other

What are your likes and dislikes?

Please describe some things you enjoy doing in your free time and things you would avoid doing!

Are there any aspects of your life that you would like to change? What would you like the future to bring?

Please select the option that best describes your preferred social group

I'm happy to be involved with small and medium sized social groups of up to 8 people

I would need an element of 121 support within the group activities

I would prefer to be in small social groups of 4 people or less

Do you have any mobility issues that may impact your ability to join walking groups for example?

Yes

No

Please provide a brief description of your availability and approximately how many hours a week of support you would like with us

Any behavioural concerns or triggers we need to be aware of and include in our risk assessments?

Please include as much as you feel comfortable disclosing in this form. Any potentially sensitive information relevant to the support can be discussed in person at the home visit.

Do you have any communication needs which would require additional support?

No

If yes, please give a brief description

Please choose the option that best describes your funding situation

I have social care / NHS funding in place and know the hours I have available

I am unclear on my funding situation and need to look into this further

I am in the process of applying for social care / NHS funding

I am self-funding and am not part of a social care team

OUR ACTIVITIES

Improving Mental Health since 2012

General enquiries form:
Feel free to send us a message and we'll aim to get back to you within 48hrs.
Scroll a bit further down for our new online referral form!

GET IN TOUCH

Online Referral form

07591 555 858

info@aebal-leisure.com