WELLBEING REGISTRATION FORM Your details Contact phone number * Email * Which of the following methods can we use to contact you? Please tick all that apply. * Can we leave a voicemail? * If you’d like to keep up-to-date with our latest news and how you can get involved, sign up to our client mailing list. Your information will only be used to send out Mind in Bradford mailings. Would you like to subscribe to our client mailing list? * Emergency contact details Contact phone number * Access and communication needs Do you have any accessibility or communication needs that you would like us to be aware of? Please tick all that apply: If you have ticked any of the above, please give details, including adjustments required here: Sources of support Please list organisations and services you receive support from below, including NHS secondary mental health services, council, voluntary sector services and friends or family. Risk management We use risk information to ensure the safety of our groups whilst supporting as many people as possible to access our services. Is there any reason you cannot or should not come into contact with children, young people or vulnerable adults? * If yes, please give details: Do you have any serious medical conditions we need to be aware of? * If yes, please give details: Are there any other risks we need to be aware of? *
This includes risk to you (from yourself or from others) and risk to others from you (including staff and other people using our services).
If yes, please give details: Additional information How did you hear about us? * Do you have any caring responsibilities – for example, do you look after a relative, friend or neighbour who cannot manage without your help due to sickness, age or disability? * Main reason for seeking support (select only one) Diversity monitoring We use the information below to help us improve fair access to our services for all, and to understand if there are any groups we could be better at supporting.
The information is collected for research purposes and will not affect your involvement with Mind in Bradford in any way. Summaries of demographic information may be shared with funders, but it will not include personal details and cannot be linked back to an individual.
If you have any questions please contact us at [email protected] Do you consider yourself to be disabled, or to have a long-standing condition or illness that causes difficulty with day-to-day activities? By long-standing we mean that is has lasted or is expected to last at least 12 months. Tick all that apply. DECLARATION AND SIGNATURE All of your personal information is processed securely in line with data protection regulations. Please read, sign and date the declaration below: I confirm that all the information given in this form is accurate *
Please note, Wellbeing services are offered as group support only. Although your induction and any subsequent review will be done on a 1-1 basis, the regular support offer of the Wellbeing Service is group support. Our Wellbeing timetable is available on the Mind in Bradford website. Please be aware that this is not a 1-1 or Counselling service.
Full details on how we use your data and keep it safe can be found