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Registration Form
ARTiculate and is for 16-25 year olds who live in Barnet who wish to use the arts to support their mental health and emotional well-being. Please complete the form as best as you can and answer all
the questions honestly. The information you provide will be treated in the strictest confidence.
If you need help in completing this form please speak to the ARTiculate Project Manager who will be happy to help.
Personal details
Name
‘Known as’
Address
Post-code
Phone number
Email address
Date of birth
AgeSexEthnic Background (please tick)
White – English Asian - PakistaniWhite – Scottish Asian - BangladeshiWhite – Welsh ChineseWhite – Irish Mixed Ethnic BackgroundAny other white background (please state)
White and Black Caribbean
Black – Caribbean White and Black AfricanBlack – African White and AsianAny other black background (please state)
South American
Asian – Indian Any other background, please state
What areas of Barnet are easy for you to get to?
COMMUNITY FOCUS, First Floor, Friary House, Friary Park, Friern Barnet, London N20 ONR~ www.communityfocus.co.uk ~ [email protected] ~
Charity registration number 1139259 ~ Company registration number 7442636
How did you hear about us? (please tick)
Phone Social Media
Web-site/ Email A Health Worker
Word of mouth, e.g. friend or family member
Other
If other, please state
Emergency contact details (1)
Name
Relationship to you, e.g. parent or carerAddress
Post-code
Phone number
Email address
Any other notes to be aware of (for office use only)
Whereabouts contact details (2)
Name
Relationship to you, e.g. parent or carerAddress
Post-codePhone numberEmail addressAny other notes to be aware of (for office use only)
COMMUNITY FOCUS, First Floor, Friary House, Friary Park, Friern Barnet, London N20 ONR~ www.communityfocus.co.uk ~ [email protected] ~
Charity registration number 1139259 ~ Company registration number 7442636
What are your interests/ hobbies do you have?
What kind of art do you want to do with ARTiculate?
PaintingSingingDanceTextilesPhotographyCreative WritingDrummingCeramicsJewellery MakingSculptingMusicDrama
What time is below suits you the most to do an ARTiculate project? Think about other commitments that you may have, e.g. work, college or child-care. Most ARTiculate projects will happen during the week, between Monday to Friday.
Afternoon 2-4pmLate afternoon/ early evening 4-6pmEvening 6-8pm
What made you think that the ARTiculate project would be an advantage or use to you? What made you think that the ARTiculate project would be beneficial to your mental health?
What are you looking forward to about the course?
COMMUNITY FOCUS, First Floor, Friary House, Friary Park, Friern Barnet, London N20 ONR~ www.communityfocus.co.uk ~ [email protected] ~
Charity registration number 1139259 ~ Company registration number 7442636
I don’t mind what art form I doWould like to do an ARTiculate course with a mix of art
Does anything worry you about the course?
Have you ever been involved with Community Focus before, e.g. on the FLY Project?
Yes/ No
If yes, please state ………………………………………………………………………………………….
In relation to your mental health and emotional well-being: -
How would you describe your issues/ difficulties/ challenges In relation to your mental health?
Are there any triggers (things that really upset you) or early warning signs (things that would tell staff that you are becoming unwell) that you know of?
Do you use any other services in Barnet, e.g. Youth Services, Counselling, Statutory Mental Health Services, Barnet Centre for Independent Living & Charities? Yes/ No
If yes, please provide further details.
COMMUNITY FOCUS, First Floor, Friary House, Friary Park, Friern Barnet, London N20 ONR~ www.communityfocus.co.uk ~ [email protected] ~
Charity registration number 1139259 ~ Company registration number 7442636
Do you feel you have a problem with drug use (including alcohol or cannabis)? Yes/ No
If yes, please provide further details.
Do you have a ‘Recovery Action Plan’? Yes/ No
Do you know what a ‘Recovery Action Plans’ is? Yes/ No
If you answered no to both these questions, don’t worry.
Are you or have you ever been involved, at risk or have been involved with the Youth Offending Team, police or community support? Yes/ No
If yes, please provide further details.
Do you have any disability access issues or medical issues, e.g. allergies that we need to be aware of? Are you currently on any medication? Please give details…
Is there anything else you want to ask the ARTiculate staff?
COMMUNITY FOCUS, First Floor, Friary House, Friary Park, Friern Barnet, London N20 ONR~ www.communityfocus.co.uk ~ [email protected] ~
Charity registration number 1139259 ~ Company registration number 7442636
ARTiculate will throughout the programme be taking photographs of young people participating within ARTiculate activities, e.g. projects, celebration event and volunteering. This is to report back to our funders, evidence our work and promote what ARTiculate does (both in print and online).
If you do not wish to have your photo taken and put in print, e.g. funding reports or posters etc. please the boxIf you do not wish to have your photo taken and put online, e.g. Facebook, Twitter or the Community Focus web-site, please tick the box
Declaration
I declare that to the best of my knowledge and belief the information on this form is true and correct. If my contact details change during my time with ARTiculate,
Signature: Date:
Thanks for your time and effort in completing this registration form. When completed please return the form to the contact below and James, the ARTiculate Project Manager will be in touch
in due course.
James Hughes
ARTiculate Project Manager
Community Focus, First Floor, Friary House, Friary Park, Friary Road, Friern Barnet, London, N20 0NR
- 07948 111 748 - [email protected]
For office use only YES NO YES NO
Have you discussed ARTiculate’s confidentiality policy (and limits) and ‘duty-of-care’
Is the young person comfortable with this?
Have you discussed who the emergency contact person should be?
Is the young person comfortable with this?
COMMUNITY FOCUS, First Floor, Friary House, Friary Park, Friern Barnet, London N20 ONR~ www.communityfocus.co.uk ~ [email protected] ~
Charity registration number 1139259 ~ Company registration number 7442636
