Community Enrolment Form

Referrer details

*If you are self-referring please skip this section and complete from the beginning of the next section*

Applicant Details

Ethnicity and Diversity

Health Questionnaire

Click or drag a file to this area to upload.
If you do not have a criminal record, please put N/A

GP Details

Emergency Contact Details

Informed Consent

Brent, Wandsworth & Westminster Mind will keep basic information about you on our databases so we can track your progress through our service(s) and contact you when necessary. In addition we will hold a written record of your contact with us. These records will be kept in line with Brent, Wandsworth & Westminster Mind’s guidelines, and in compliance with the General Data Protection Requirements 2018.

Consent to hold and store information

Consent to obtain information

Consent to share/pass information

Consent for photographs and videos

*For use on all marketing activity such as the charity’s printed annual reports, leaflets or any publicity material and in events exhibitions/ conferences, on the charity’s websites, as display work at the charity’s events, training or conferences*

Consent for story telling

*For use on printed annual reports, leaflets or any publicity material, and in events/exhibitions, on the charities websites, share with commissioning agencies.

Consent to use my Photography, film, music and/or any artwork

*For use on the charity’s printed annual reports, leaflets or any publicity material and in events exhibitions/ conferences, training etc, on the charity’s websites, as display work at the charity’s events, training or conferences

General Privacy and Understanding

I understand that I can

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