Sydenham Garden Resource Centre
28a Wynell Road
London
SE23 2LW
Tel: 020 8291 1650
Referral Form
Please refer to our guidelines or contact us with any queries. You can attach additional information. An electronic version of this form is available on the front page of our website.
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Date of Referral: Click here to enter a date.Please assess the person below for a co-worker placement
Name:Date of birth:
Address:
Tel (home):(mobile): Email:
(It is essential to provide at least one contact phone number.)
In which project has your client expressed the most interest:
Art & Craft ☐ Garden ☐ Sow & Grow (Dementia)☐ Growing Lives☐
Main reason for referral (incl. medical diagnosis):
Other health problems we should be aware of e.g. insulin dependent diabetes, epilepsy, heart condition, back pain etc.:
History of violence/aggression, drug/alcohol abuse, self-harm (please include a risk assessment if one is in place):
Are they currently on CPA: Yes ☐ No ☐
If yes, Care Co-ordinator’s Name:
Address (including postcode):
Tel:Email:
Important: Please complete this section in full even if you have made a previous referral to Sydenham Garden.
Registered Charity No. 1108100. Company limited by guarantee. Registered in England No. 05291164
Sydenham Garden Resource Centre
28a Wynell Road
London
SE23 2LW
Tel: 020 8291 1650
Referrer Details:
Name:
Position:
Organisation:
Address (including postcode):
Tel:
Email:
Other Support:
Name:
Position/relationship:
Organisation:
Address (including postcode):
Tel:
Email:
Registered Charity No. 1108100. Company limited by guarantee. Registered in England No. 05291164
Sydenham Garden Resource Centre
28a Wynell Road
London
SE23 2LW
Tel: 020 8291 1650
☐Please tick to let us know your client understands and consents to our processing of their data contained on this form.
☐Please tick if you have made a prior referral to Sydenham Garden and your contact details have changed in the last six months.
☐Please tick if you would like to know if your client has been invited to an introduction. NB We can only do this if you supply your email address.
Thank you for your referral.
Transparency notice to be shown to your client
Sydenham Garden (SG) records certain information about you. This information is overseen by SG’s Data Controller (currently Tom Gallagher). The Data Controller can be contacted at the Resource Centre Office.
We record your name, address and telephone details as well as details of an emergency contact. We also record your mental health diagnosis and important information (such as a risk assessment) sent to us by the health professional who referred you, in order to give you the safest care possible. The legal basis for holding this information is called ‘legitimate interest’. We will hold your records for a further 6 years after you complete your time as a co-worker with us, in line with NHS policy.
We will never pass your information onto an external individual or organisation without seeking your consent first. While reports on the effectiveness of the charity’s work are sent to funders including Lewisham CCG and Lewisham Council, it is not possible to identify individuals from these reports.
You have the following rights relating to the information that we hold about you:
-A right to see the information we hold on you (access). SG will agree to your request as soon as practicably possible and not later than 1 month from the date of request.
-A right to request any errors in your information are corrected (rectification). SG will agree to your request as soon as practicably possible and not later than 1 month from the date of request.
-A right to request your information is erased from Sydenham Garden’s records (erasure). If there is no good reason for SG to hold your information, SG will agree to your request to erase the information it holds on you. However, while you are a co-worker, there will be a continuing good reason to hold the information to help us to provide you with the best care possible.
-A right to complain to the Data Controller using the SG Complaints Procedure. If you feel we have not responded correctly to your request please follow the SG Complaints Procedure. Should you not be satisfied after using our complaints procedure you have a right to complain to the Information Commissioners Office via: or by the Helpline on 0303 123 1113.
Registered Charity No. 1108100. Company limited by guarantee. Registered in England No. 05291164