Community Enrolment Form

Referrer details

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

Name

First

Last

Profession

Phone

Email

Organisation

Applicant Details

Date of referral *

Name *

First

Last

Date of birth *

Telephone Number *

Email *

Address and Postcode *

Preferred method of contact *

Phone call
Text
Email

Borough *

Brent
Wandsworth
Westminster

Sexual orientation *

Gender Identity *

Current Employment Status

Ethnicity and Diversity

Ethnicity *

Religion

What activity/program/service are you registering to take part in it?

Interest

Health Questionnaire

Have you previously suffered or are you currently suffering from a mental health issue (e.g. Anxiety, Depression, OCD, Bipolar etc..)? *

If you are currently receiving support from any other mental health services, please provide contact details: (e.g. Community Mental Health Team / Charity / Supported Housing etc..) *

Do you have any known risks? *

If you are receiving support from another mental health service, please upload an up-to-date risk assessment

Click or drag a file to this area to upload.

A criminal record (please list offences below) *

If you do not have a criminal record, please put N/A

Do you have a disability *

Yes
No

If you answered yes to the previous question, please give us a brief overview (e.g. physical mobility impairment, sensory, learning disability, long term illness etc..)

Do you have any medical or health conditions? *

Yes
No

If you answered yes to the previous question, please give us a brief overview (e.g. epilepsy, heart disease, diabetes etc)

GP Details

GP Name *

First

Last

Surgery Name *

Contact Number *

Emergency Contact Details

Name *

First

Last

Relationship to you *

Telephone Number *

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

I would like to subscribe to the BWW Mind newsletter and communications. *

Yes
No

I agree to give permission to Brent, Wandsworth & Westminster Mind to keep written details relating of my contact with them and to hold information on its database(s). I understand this information is required in order to provide the service to me and that without this information I may not be able to receive the service. *

Agree

I agree to give consent for Brent, Wandsworth & Westminster Mind to keep records about me both electronically and in hard copy. *

Agree

I agree to give my consent for Brent, Wandsworth & Westminster Mind to hold information on appropriate databases and written details of my contact with them. I understand that access to this information may be provided to the relevant London Boroughs Commissioning group if requested. *

Agree

Consent to obtain information

I agree to give my consent for Brent, Wandsworth & Westminster Mind to contact relevant agencies to gather information about me (including copies of correspondence and reports) from relevant organisations such as: GP, Adults Mental Health, psychiatric services, Recovery team and other statutory professionals involved in my care, Police, Forensic & emergency services, Brent Council, Westminster City Council or Wandsworth Council, Utilities Companies, DWP, Social Security, Housing Benefits Job Centre Plus *

Agree

Consent to share/pass information

I agree to give my consent for Brent, Wandsworth & Westminster Mind to contact relevant agencies to Mind to share information about me with the following organisations: GP, Adults Mental Health, psychiatric services, Recovery team and other statutory professionals involved in my care, Police, Forensic & emergency services, Brent Council, Westminster City Council or Wandsworth Council, Utilities Companies, DWP, Social Security, Housing Benefits Job Centre Plus *

Agree
Disagree

Consent for photographs and videos

I agree to give my consent for Brent, Wandsworth & Westminster Mind to use any photographs or video of myself for the following purposes: *

Agree
Disagree

*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

I agree to give my consent for Brent, Wandsworth & Westminster Mind to use my anonymised story/case study *

Agree
Disagree

*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

I agree to give my consent for Brent, Wandsworth & Westminster Mind to use any photographs, films, music and/or any original artwork I may produce *

Agree
Disagree

*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

I understand that Brent, Wandsworth and Westminster Mind may in future sell any donated artwork and that all proceeds will go to the charity. *

Agree
Disagree

I would like to have any of my work credited to me *

Agree
Disagree

General Privacy and Understanding

I understand that Brent, Wandsworth & Westminster Mind will act in accordance with the General Data Protection Regulations 2018 and will only share information on a need-to-know basis. I further understand that there are specific and limited exceptions to this confidentiality which include the following: When there is risk of imminent danger to myself or to another person, the practitioner/organisation is ethically bound to take necessary steps to prevent such danger. When there is suspicion that a child or adult is being sexually, physically, emotionally abused or neglected, or is at risk of such abuse, the practitioner/ organisation is legally required to take steps to protect the vulnerable adult or child, and to inform the relevant authorities. When a valid court order is issued for case records, the practitioner and the organisation are bound by law to comply with such requests. *

Agree

I understand that I can

Withdraw my consent to any of the above at any time; Request details of the information BWW Mind hold of me; Request BWW Mind to remove data they hold of me. *

Agree

Name

First

Last

Referrer details

Applicant Details

Ethnicity and Diversity

What activity/program/service are you registering to take part in it?

Health Questionnaire

GP Details

Emergency Contact Details

Informed Consent

Consent to hold and store information

Consent to obtain information

Consent to share/pass information

Consent for photographs and videos

Consent for story telling

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

General Privacy and Understanding

I understand that I can

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