Online referral form Name of potential member: Date Of Birth: Address: Post code: Email: Home tel: Mobile: Which Studio are you interested in attending: BristolNorth London (Dalston)South London (Croydon)Remotely: via Internet or phone Which Group are you interested in attending: Art Therapeutic: Whole Day (All sites)Online Art Sessions: 12x (All Sites)Merton Online Art Group: 12x SessionsPerformance Art (Dalston)Creative Writing (Bristol) How did you hear about Studio Upstairs? Friend / AcquaintanceHealth professionalSearch engineStudio Upstairs ExhibitionStudio Upstairs Leaflet / Poster Referral details: SelfGPCare CoordinatorSocial WorkerEarly Intervention TeamCommunity Mental Health TeamProbation Officer/TeamOther Referral contact Name: Position: Address: Postcode: Telephone: Email: Funding of membership fees Funding is not confirmed, though has been applied for: YesNo Funding is confirmed and it will be through: Local AuthorityDirect PaymentNHSSelf Funding Name of Local Authority/ NHS Trust: Self Funding - are you in receipt of any of the following benefits: NonePersonal Independence Payment: Enhanced ratePersonal Independence Payment: Standard rateDisability Living AllowanceEmployment and Support AllowanceJob Seekers AllowanceCarers Allowance Additional information: