Access our support

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

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. 

Employment information

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

GP details (if known)

Details of referrer (if completing on behalf of someone)

Further information

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.

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.