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About us
Our Mission & Values
Our Trustees
Our Senior Leadership Team
Our Team
Work for us
Policies
Services
Monthly Activity Calendar
Talking Therapies
Peer Support Groups
Ramblers Wellbeing Walks
Mindfulness
Wellbeing Courses
Drop-in Support & Signposting
Creative & Physical Activities
Shifa Asian Women’s Support
Information
Coronavirus & Your Wellbeing
Mental Health Conditions
Wellbeing Top Tips
Wellbeing Apps
Wellbeing Activities
Supporting Others
Other Helpful Organisations
Workplace Wellbeing
Support Us
Donate
Help us fundraise
Mental Health Awareness Week 2022
Fundraising Challenges
Volunteer for us
Volunteer application form
Other Ways to Support Us
News & Blog
Blog
Latest News
Press Releases
Contact Us
Emergency Contacts
Wellbeing Tracker
Referral Form
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Referral Form
Mandy
2022-03-03T14:14:19+00:00
Referral form
Please use this form to refer yourself or on behalf of someone else.
Name
*
First
Last
Preferred Pronoun
Date of birth (dd/mm/yyyy)
*
Address
*
Which borough do you live in?
*
Postcode
*
Landline telephone number
Mobile telephone number
*
Email address
*
Preferred method of contact?
*
Call (Landline)
Call (Mobile)
Text
Email
Post
Can we leave a voicemail?
*
Yes on Landline
Not on landline
Yes on mobile
Not on mobile
Dependants
Do you have caring responsibilites?
*
Yes
No
If so, please provide details
*
Emergency contact / next of kin
Name
*
First
Last
Relationship to you
*
Address if different from above
*
Contact number
*
Email address
Is this person aware you are sharing their details with us? *
Yes
No
*If this person is not aware, we will need to contact them to obtain consent to hold their details.
GP Practice Name:
*
Address:
*
Telephone Number:
*
Are you taking any regular medication? If so, please detail below.
*
Yes
No
Medication details
*
Duration
*
Name & contact details of any other professional healthcare support you receive.
*
Referred from
*
Self
Other
If other, please give name and contact details.
*
Please provide some background information about your mental health and how you are at the present time.
*
What do you hope to achieve from our services?
Short term goals
*
Long Term goals
*
Please indicate which services interest you:
*
Anxiety & depression support group (Tuesday)
Anxiety support group (Wednesday)
Young Persons support group
Ramblers wellbeing walks
In-Person Mindfulness
Online Mindfulness
Mindfulness MBCT Course
Parental support group
Counselling
Cuppa & Chat
Nature based activities
Not sure / need advice
Newsletter
We have a regular newsletter that keeps you up to date with all that we are doing. Please indicate below if you are happy to receive it.
*
Yes
No
Data Protection and Confidentiality Statement
By completing this you agree that the information recorded on these forms will be held on the secure Woking Mind Service database and will be managed in line with the General Data Protection Regulation, Data Protection Act 2018.
Photo Consent
Woking Mind would like to use photos showing members and volunteers participating in activities, for information and marketing purposes. This may include, for example, our newsletter, website, leaflets, media releases, social media and other marketing materials. We may like to include a first name with these photos.
*
I give permission for Woking Mind to use my photograph and first name
I give permission for Woking Mind to use my photograph, but NOT MY FIRST NAME
I DO NOT give permission for Woking Mind to use either my photograph or first name
Equality Monitoring
This information is confidential and will be used for statistical analysis only. Woking Mind believes in the equality of opportunity and access for all. We aim to ensure that all our services are inclusive and accessible to all. You do not have to disclose any information you do not wish to share. By completing the following information, you consent to this data to be shared for reporting purposes.
How would you describe your ethnic or cultural origin?
Asian:
Please select
Afghan
Bangladeshi
British
Indian
Pakistani
Any other background
Black:
Please select
African
British
Caribbean
Any other Black background
White:
Please select
British
Easter European
Irish
Roma
Traveller
Any other background
Mixed:
Please select
Asian & White
Black African & White
Black Caribbean & White
Black & Asian
Any other mixed background
Other ethinic group:
Please select
Chinese
Middle Eastern
Any other ethnic background
Rather not say
How would you define your gender identity?
*
Please select
Male
Female
Other
Rather not say
How would you define your religion?
*
Please select
Buddhist
Christian
Hindu
Jewish
Muslim
Sikh
Spiritual
None
Other
Rather not say
How would you define your sexual orientation?
*
Please select
Bisexual
Gay
Hetrosexual
Lesbian
Other
Rather not say
Do you consider yourself to have any of the following health conditions or disabilities?
*
Please select
Additional Learning Needs
Additional Hearing or Vision Needs
Mental Health Needs
Physical Health Needs
Accessibility Needs
None
Rather Not Say
Please confirm that you have completed this form to the best of your knowledge by adding your name and today's date below.
Name
*
First
Last
Date
*
Send
This field should be left blank
