Lamplight API response

First name

Last name

Address 1

Address 2

Address 5

Postcode

Email address

Mobile phone

Phone number

For people who are not receiving support for mental health The self-referrals is for: 3-week Studio Discovery Programme 3 hours per week FREE For people who are NOT eligible for financial support. Check ALL boxes to confirm we can contact you regarding our service

By post

By email

By mobile

By text message

Other information

Date of birth

Gender

Ethnic Group

Briefly describe your musical interest / Experience

Have you ever received Hospital Treatment for your Mental Health

Have you ever been under a section of Mental Health Act

Are you currently in Education / Training

Are you currently Working

Receiving any of the following benefits

Eligible for Free or Subsidised Travel on Public Transport

Emergency Contact Details

First and Last Name of person to contact in case of Emergency

Phone Number of person to contact in case of Emergency

Contact details for other people in an artist's life

GP Surgery Name Registered with

GP Surgery Number

Confirm your consent for us to contact you for the purpose of progressing your self-referral to Key Changes

PLEASE CONFIRM THAT BOTH OF THE FOLLOWING CRITERIA APPLY TO YOUR SELF REFERRAL:

I am NOT currently receiving support from anywhere for my mental health. I understand that otherwise the person providing support should make this referral on my behalf.

The information provided is correct and I accept that if found to be false would result in cancellation of any place that might be offered.

KEY CHANGES SELF REFERRAL FORM for 3-WEEK STUDIO DISCOVERY PROGRAMME

Other information

Emergency Contact Details