Community Wellbeing Referral Form

The following questions help us understand your situation so we can offer the best support possible. Please answer as honestly as you feel comfortable. We will always provide support regardless of your circumstances, but the more accurate your answers, the better we can tailor our services to your needs.

First name

Last name

Email

Phone

I am completing this form for

Myself

On behalf of someone else

Which service are you interested in?

Yoga Therapy

Cold Water/Contrast Therapy

Other

If other, please specify

Which of the following groups do you identify with (tick all that apply)

If other, please specify

Support Network

I have family or friends I can rely on

I have some support but limited

I have little or no support

Age

Gender

Living Situation

Living alone

Living with family / partner

Living with friends / housemates

Supported housing / care facility

If other, please specify

Is there anything else you’d like us to know about your current situation?

What would you like support with or hope to achieve through Polarity?

Opening Hours & Directions

CWMBRAN

Polarity Wellbeing Centre

Unit 4 Christian Centre

Grange Industrial Estate

Cwmbran, NP44 8HQ

Monday 07:00 - 08:30 / 17:00 - 19:30

Tuesday 07:00 - 08:30 / 17:00 - 19:30

Wednesday 17:00 - 19:30

Thursday 07:00 - 08:30 / 17:00 - 19:30

Friday 07:00 - 08:30 / 11:30- 13:00 / 16:30 - 19:00

Saturday - 09:00 - 12:30

Sunday 09:00 12:30