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Confidentiality

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: https://www.mind-blmk.org.uk/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: Mind BLMK reserves the right to disclose information given in confidence to a relevant third party which poses a risk to the service user, poses a risk to other people, is against the law, or poses a risk to the safety and welfare of a child.

To access our services, please complete this form and we will contact you to discuss next steps. Please provide as much information as possible.
Your details
Your Address
Employment Information
Emergency Contact Information
GP Details (If known)
Details of Referrer (if completing the form on behalf of someone)
Further information
Equal Opportunities and Disability Monitoring

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