Thank you for your interest.

Breathe Sing Warwickshire’s programmes are carefully tailored to the needs of people with chronic lung & respiratory conditions. They are open to people living or working in Warwickshire, or with a family connection to the county. You can use this form to refer a patient or to refer yourself directly.  

We look forward to welcoming you. 

Referral details (if referring a patient please complete this section) Name: Role: NHS Trust: Relationship to patient: Any general notes:
Participant’s details (to be completed by or on behalf of the participant) *First name/s: *Surname: *Age *Post Code: *Phone number: *Email: *Please specify the respiratory condition you have been diagnosed with:
Chronic Obstructive Pulmonary Disease (COPD)
Interstitial Lung Disease (ILD)
Idiopathic Pulmonary Fibrosis (IPF)
Lung cancer
Breathlessness following hospital stay
Long Covid

Other (please specify) *Do you experience breathlessness on a regular basis? If you answered yes to the question above, please give detail below: Do you have any access or support needs to ensure you can take part in this activity? (E.g. wheelchair access, captioning for online activity, large print information, sign language interpretation) If you answered yes to the question above, please give detail below:
Emergency contact *Please provide Emergency contact information (should anything happen to you at Breathe Sing)
Emergency contact name: Emergency contact telephone number: What is their relationship to you?
I agree to Breathe Arts Health Research occasionally taking screenshots or short recordings of online sessions for promotional and reporting issues. (No personal details will be visible).

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