C4W Enquiry/Referral form

Use this form to refer someone to the Cycling for Wellbeing program, or if you have a general enquiry.

If referring someone else, please make sure they have given permission to be contacted by us and note that all information will remain confidential and only be shared on a need-to-know or anonymised basis.

Your Name

Your Email Address(Required)

Your Phone Number

Your organisation name? (put n/a if not appropriate)(Required)

Are you enquiring for yourself or referring someone else to the Cycling for Wellbeing Program?(Required)

If referral is for yourself / you have an enquiry

Type your message here and press SEND (at the bottom of the page)

If referral for someone else:

Full Name of the person you are referring(Required)

Phone number of the person you are referring (please make sure they have given permission to be contacted)

Email of the person you are referring (please make sure they have given permission to be contacted)

Which borough does the person you are referring live in?(Required)

If ’Other’ please state which borough here:

Add any other information regarding the referral that may be useful for us to know:

What is the best way to contact the person to make a booking? (select multiple)(Required)

Phone (may need support with booking)

Email (can make booking themselves with a weblink)

Does the person you are referring suffer from any of the following: (select all that apply):

Mental Health condition (mild or severe)

Physical Health condition

Social Isolation

Poor General Fitness/Low Activity levels

Other

Type of organisation you work for: