Shore-Up referral form
The group sessions will explore the relationship between what we do and our health.

Aims of the group:
Providing space and support for individuals to:
• think about what goes on for them in daily life
• consider how all aspects of individual circumstances, health and wellbeing interact with the things they need and want to do in life
• identify changes they might want to make in daily life
• have the opportunity to make changes and see how it feels
• get support and understanding throughout the process

Group members will be asked to attend each session and once the group has started, there will be no additional members joining.

This referral form can be used for self-referral or can be completed by health professionals or support services.

Venue:
CATCH
Hovingham Ave
LS8 3QY

When:
13th September to 25th October on Wednesday mornings 10am to 12.30pm

​There will then be 2 further sessions on:
Wednesday 8th November (10am -12.30pm)
Wednesday 29th November (10am -12.30pm)
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Name *
Date of Birth *
MM
/
DD
/
YYYY
Referrer details *
Contact details: please provide details of phone number and /or email address for both yourself and referrer (if applicable) *
Would you prefer us to contact you or your referrer (if applicable)?
 *
What's the best way for us to contact you? (please tick all that apply) *
Required
Address *
GP surgery *
Do you use any other health or support services? (please give details)
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