To access our services, please complete this form and we will contact you to discuss next steps. Please provide as much information as possible. If you would prefer to fill out a paper form, you can download one here.

Your details

Name

Surname

Tel no

Mobile

Date of birth

Address

Town

Postcode

Please complete this section carefully. Supporting you to access the right services is very important to us but it isn't always easy to make contact, so listing as many contact options as possible will help us to help you more quickly.

How would you like us to contact you? *

Home Phone
Email
Mobile Phone
Post

Is it OK for us to leave a message? *

Employment information

Employed
Unemployed
Military veteran
Carer

Emergency Contact Information

Please confirm that you have the consent of the person for Mind BLMK to contact in an emergency by ticking the checkbox below

Single Checkbox Field *

My emergency contact has given their consent

Name

Relationship to you

Contact no.

GP details (if known)

GP name

Surgery

Surgery address

Town

Post code

GP Tel number

Are you a healthcare professional? *

If you are a health or social care professional helping a person to access our services please attach a risk assessment and/or care plan. This is a requirement. *

Click or drag a file to this area to upload.

Files allowed: doc, docx, pdf

Details of referrer (if completing on behalf of someone)

Name of referrer

Organisation address

Referrer email

Referrer phone

Are you happy for us to give feedback to your referrer?

Further information

Which services would you like to access or like more information about? *

Mentoring
Peer Support Groups
Mind Matters
Mind Matters Plus
Counselling (Fee Paid)
Not sure or other

Please can you tell us more information about what support you are looking for and why? *

Is there any additional information we need to know for you to access our services? (e.g. language, access issues, disability)

How did you hear about us?

GP
CMHT / Recovery Team
Social Worker
Counselling
IAPT / Wellbeing Service
Family or Friend
Other (please specify)

If 'other', please specify

Equal Opportunities and Disability Monitoring

We aim to provide equal opportunities and fair treatment for everyone. We would like you to complete this form in order to help us understand who we are reaching and to better serve the community. All details will be treated as confidential and are held in accordance with the Data Protection Act 2018 and the EU General Data Protection Regulation 2018.

Age group

17 or under
18-29
30-39
40-49
50-59
60-69
70 and over
Prefer not to say

Gender

Male
Female
The gender above is not the one given to me at birth
Prefer not to say

Religion / Faith

No religion / faith
Christian (any denomination)
Buddhist
Hindu
Sikh
Muslim
Jewish
Other
Prefer not to say

Sexual orientation

Bisexual
Gay man
Lesbian
Heterosexual
Other
Prefer not to say

Disability: Are your day-to-day activities limited because of a health problem or disability which has lasted or expecting to last for at least 12 months?

No
Yes, limited a lot
Yes, limited a little
Prefer not to say

If yes, please specify briefly

Ethnicity

White English / Welsh / Scottish / Northern Irish / British
White Irish
White Gypsy or Irish Traveller
Any other white background (please specify below)
Mixed White and Black Carribean
Mixed White and Black African
Mixed White and Asian
Any other mixed background (please specify below)
Black or British African
Black or British Caribbean
Any other black background (please specify below)
Asian or British Indian
Asian or British Pakistani
Asian or British Bangladeshi
Asian or British Chinese
Any other Asian Background (please specify below)
Prefer not to say

Please specify ethnicity

Data Protection and Confidentiality

Mind BLMK adheres to the Data Protection Act 2018’s principles of good information handling and the EU General Data Protection Regulation 2018.

This means that your information will be:

• Fairly and lawfully processed

• Processed for limited purposes

• Adequate, relevant and not excessive

• Accurate and up-to-date, not kept for longer than necessary, and secure.

Please indicate below if you consent to Mind BLMK collecting, recording and processing your personal data for the purpose of providing you with support and to ensure your health, safety and wellbeing. Mind BLMK will use your information appropriately and in line with our Privacy Policy which you can see here: Privacy Policy.

Your details will not be shared with anyone else without your consent. If you have any concerns or questions about how your personal data is collected and used, please ring our HQ on 0300 330 0648 or email [email protected]. Please note that without your consent, you will not be able to submit this form and access Mind BLMK’s services.

Please note: Where information is given in confidence that Mind BLMK believes poses a risk to the service user, a risk to other people, a risk to the safety and welfare of a child, or is against the law, we reserve the right to disclose that information to a relevant third party.

Single Checkbox Field *

Please tick the box to confirm you agree with the above statement

First Name

Last Name

Data Protection and Confidentiality

Mind BLMK adheres to the Data Protection Act 2018’s principles of good information handling and the EU General Data Protection Regulation 2018.

This means that your information will be:

• Fairly and lawfully processed

• Processed for limited purposes

• Adequate, relevant and not excessive

• Accurate and up-to-date, not kept for longer than necessary, and secure.

Single Checkbox Field *

Please tick the box to confirm you agree with the above statement

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