Wellbeing Form | Mind in Bradford

WELLBEING REGISTRATION FORM

Your details

Full name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of birth *

Contact phone number *

Email *

Which of the following methods can we use to contact you? Please tick all that apply. *

Phone
Text
Email
Post

Can we leave a voicemail? *

Yes
No

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? *

Yes
No

Emergency contact details

Full name *

First

Last

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? *

Yes
No

If yes, please give details:

Do you have any serious medical conditions we need to be aware of? *

Yes
No

If yes, please give details:

Are there any other risks we need to be aware of? *

Yes
No

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? *

Yes
No

Main reason for seeking support (select only one)

Checkboxes *

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]

Age

Religion

Gender

Sexual orientation

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.

Ethnicity

Prefer not to say

White

Asian / Asian British

Black / Black British

African
Caribbean
Other Black

Mixed / Multiple

White and Asian
White and Black African
White and Black Caribbean
Other Mixed

Other Ethnic Group

Arab
Any other ethnic group

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 *

Yes

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 in our Privacy Policy.

WELLBEING REGISTRATION FORM

Your details

Emergency contact details

Access and communication needs

Sources of support

Risk management

Additional information

Main reason for seeking support (select only one)

Diversity monitoring

DECLARATION AND SIGNATURE

What happens next?

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