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The Planetary Healing Centre Referral Guidelines and form for Health Professionals The following are the services offered by our charity. Depending on the aims of the service there are specific entry criteria that are required. If you need more details please call our office on 0131 449 4467. HOLISTIC HEALTH PROJECT: Eligibility 1. Complementary Therapies by contribution for people who are struggling financially and affected by ill-health, including mental health issues, struggling to come to terms with diagnosis, struggling with the physical, mental and emotional effects of living with a life threatening condition, people who are homeless or at risk of becoming homeless and people hoping to cope better, gain more control of their health and wellbeing, build confidence to move on in life in more effective ways. Referral to the project can be done by Health Professionals. Individual clients can also self- refer by calling us to book and by filling in an application form to register in our project. NATURE CONNECTION FOR FAMILIES: Eligibility 1. Outdoors Nature programme for families experiencing the same as above. (Children accompanied by parent or guardian). Physical outdoors exercises has a well-documented, positive effect on health, wellbeing and resilience to stress. Our project helps reduce the symptoms and effects of ill-health and or stress as well as improves family relationships. The children work outdoors alongside their parents/carers, planting, nurturing, and learning about nature. Please indicate which project service you are referring to: HOLISTIC HEALTH PROJECT NATURE CONNECTION FOR FAMILIES A. Referring Person Name Post Organisation Address Post code Telephone No: Email: B. Client’s Details Full Name Date of Birth Age: Male Female Transgender Address Post Code Telephone: Email: Ethnic Group Main Language: Occupation: Client’s emergency contact (family member or close friend name and tel): C. Main Carer’s Details Name Relationship: Telephone: D. GP Details Name Address Post Code: Telephone: E. Other Professionals Involved. Please tick all that apply and give details: Name District Nurse Hospice nurse Other Specialist nurse Other: F. Reasons for Referral and main focus of work for the client. Please give as much information as possible to help us with our assessment. In particular, we would need to know about current conditions and medications that may present contra-indications. G. Main Symptoms Please tick all that apply: Pain Anorexia Weakness Confusion Dyspnoea/Shortness of Breath Difficulty sleeping Lack of energy/fatigue Dysphagia Anxiety Suicidal Depression Skin conditions Other: Details of patient’s current therapeutic and psychological care needs: Please give a brief description of the client’s level of mobility: Independently mobile Uses Wheelchair Other: H. Allergies None known or Uses mobility aid Stick Confined to bed Frame If Yes (please give details below) I. Medication J. Other important information Have you included any additional information with this referral? Yes Signature of Referrer: ____________________________ No Date: _______________ Please return this form via email and write in subject line confidential to: Claudia Goncalves: E-mail: [email protected] If you prefer to post it: Planetary Healing Centre’s registered office: Cockburnhill Road, Balerno, EH14 7JB.