Beam Programme Referral Form
Building Emotional Awareness and Mental Health (BEAM)
Delivered by Forward Carers and Partners, funded by the Birmingham Fairer Futures Fund
Are you completing this on behalf of someone else?
Yes (Professional Referral)
No (Self-Referral)
Carer Details
First Name:
Last Name:
Date of Birth:
Address:
Postcode:
Telephone/Mobile:
Email:
Preferred contact method:
Phone
Email
Text
Post
Are you registered with Birmingham Carers Hub?
Yes
No
Demographic Information
Gender:
Please select...
Male
Female
Non-Binary
Transgender MTF
Transgender FTM
Prefer not to say
Other
Is your gender identity the same as your sex registered at birth?
Yes
No
Prefer not to say
Ethnic Group:
Please select...
White British
Asian (Indian/Pakistani/Bangladeshi)
Black (African/Caribbean/Black British)
Mixed ethnicity
Other ethnic background
Prefer not to say
Are you a Parent Carer?
Yes
No
Are you currently working?
Yes
No
Please state the hours you work?
Full Time
Part Time
Do you consider yourself to have a disability or long-term health condition?
Yes
No
Prefer not to say
Do you identify as neurodiverse (e.g. Autism, ADHD, Dyslexia)?
Yes
No
Prefer not to say
Religion or Belief:
Please select...
No religion
Christian
Muslim
Jewish
Buddhist
Hindu
Sikh
Other
Prefer not to say
WEMWBS - Wellbeing Check
Please indicate how often you've felt this way over the last two weeks:
None of the time
Rarely
Some of the time
Often
All of the time
I've been feeling optimistic about the future
I've been feeling useful
I've been feeling relaxed
I've been dealing with problems well
I've been thinking clearly
I've been feeling close to other people
I've been able to make up my own mind about things
Support you are interested in
Please tick which type of support you're most interested in (select a max of 3):
Barefoot Wellbeing Programme
- A 6 week course held on Friday mornings at Barefoot Yoga Studios, Harborne High Street. Yoga, movement, mindfulness and creative reflection sessions led by Kam Bola, to help reduce stress and reconnect with yourself.
1-to-1 Counselling & Emotional Support
- Short-term counselling up to 6 sessions with a qualified therapist, either in-person in Selly Oak or Harborne, or online.
RESET Carers Programme - Somaia Health
- A 10-week mind-body wellbeing course combining breathwork, mindfulness and nutrition support, including a blood pressure health check held on Wednesday mornings at the Birmingham Buddhist Centre, Moseley.
Unravelled Mind Studio
- Weekly creative therapy workshops using mindful art and journaling to relax, reflect and express emotions held on Thursday mornings at the Carers hub, Selly Oak.
Age Connects Birmingham
- Caring for the Carer
- A three-week course covering movement, nutrition, rest and resilience, helping you feel stronger and more balanced held at Moorfield Hall Day Centre, Shard End. Your Cared For can also attend and be supported while you are in the session.
Ashiana Community Project - Carers Counselling & Resilience Workshops
- Individual and group sessions offering culturally sensitive emotional wellbeing support and counselling in Small Heath and surrounding areas.
Dementia Carers Count
- a 6 week course offering online and telephone mindfulness and emotional-support sessions for Carers supporting someone with Dementia.
Break and Recharge Opportunity
- A referral to Carefree overnight break
I'm unsure - please contact me to discuss options.
Error
If you are interested in the Barefoot or RESET programmes:
Can you confirm that you are fit and able to undertake physical activities
Yes
No
Can you sit on the floor comfortably?
Yes
No, I may require a chair
When would you be available for counselling sessions:
Daytime
Evening
Of the following, which of these days and counselling styles is most suitable for you:
Please select...
Mondays Remote
Mondays Face to Face Selly Oak
Wednesdays Remote
Wednesdays Face to Face Harborne
Accessibility and Inclusion
Do you have any accessibility or communication needs?
Preferred language:
Consent and Data Sharing
By submitting this form, you consent to Forward Carers CIC collecting and securely storing information in line with UK GDPR and data protection laws.
Your details may be shared with BEAM delivery partners only for the purpose of providing support.
Aggregated, anonymous data will also be used to evaluate the impact of the BEAM programme in line with Fairer Futures Fund requirements.
You can withdraw consent at any time by contacting
info@forwardcarers.org.uk
.
I consent to my information being used as described above (digital consent for online submission).
Signed:
Enter your name.
Professional Referral (if applicable)
Referral Name:
Organisation:
Job Title:
Contact Email:
Telephone:
Reason for referral/summary of need:
Does the Carer know and consent to this referral?
Yes
No
How did you hear about BEAM?
Contact Information