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ID Number: __________________
Date: __________________
Surname: ____________________________________________
First name(s): ____________________________________________
Date of Birth (dd/mm/yy): _________________ Gender: Male Female
How did you hear about the service?
Recommended by GP
Recommended by other Health Professional
Saw advertising/poster/leaflet
Recommended by friend/relative
Other (Please State): __________________________________________________
What are your reasons for joining the scheme?
To feel healthier
To control or improve my mental health & wellbeing
To increase my level of physical activity
To learn about eating more healthy food
To improve my gardening skills
To learn about how to produce my own fruit & vegetables
To improve my social life
Individual Development Plan (IDP)
New Starter Form (1)
This form is to be filled out by you (the participant) to:
a) ensure the service delivered is appropriate to meet your needs
b) enable us to measure the success of the service for yourself and/or
others
c) continually to improve the service for yourself and/or others
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Other (Please State): __________________________________________________
1. What do you think you will enjoy about the scheme?
___________________________________________________________________
___________________________________________________________________
2. What do you hope to achieve by being on the scheme?
___________________________________________________________________
___________________________________________________________________
3. What support do you think might need?
___________________________________________________________________
___________________________________________________________________
4. The Department of Health recommends that adults aged 19-64 years
undertake 150 minutes of physical activity per week. Roughly how much
time per week (in minutes) do you currently spend undertaking moderate
physical activity? (Please tick)
0-30 minutes 31-149 minutes 150 minutes+
5. On average, how many portions of fruit and/or vegetables per day do you
currently consume?
0-1 2-4 5+
5. How do you feel about your gardening skills at the current time?
1 being very poor 5 being very good (please circle number)
1 2 3 4 5
Welcome to the ‘A Place To Grow’ Community Garden
project run by Blaby District Council. We hope that you
enjoy your time with us and improve your health and
wellbeing as a result of attending our scheme.
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This page contains a tool for measuring mental
wellbeing, it is designed to record how happy and
positive you are feeling. We will ask you to complete
this form at the start of your time with us, at three
months, and follow-up again at 6- and 12-months to
see if there have been any changes.
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