Skip to content
en English▼
X
af Afrikaanssq Albanianam Amharicar Arabichy Armenianaz Azerbaijanieu Basquebe Belarusianbn Bengalibs Bosnianbg Bulgarianca Catalanceb Cebuanony Chichewazh-CN Chinese (Simplified)zh-TW Chinese (Traditional)co Corsicanhr Croatiancs Czechda Danishnl Dutchen Englisheo Esperantoet Estoniantl Filipinofi Finnishfr Frenchfy Frisiangl Galicianka Georgiande Germanel Greekgu Gujaratiht Haitian Creoleha Hausahaw Hawaiianiw Hebrewhi Hindihmn Hmonghu Hungarianis Icelandicig Igboid Indonesianga Irishit Italianja Japanesejw Javanesekn Kannadakk Kazakhkm Khmerko Koreanku Kurdish (Kurmanji)ky Kyrgyzlo Laola Latinlv Latvianlt Lithuanianlb Luxembourgishmk Macedonianmg Malagasyms Malayml Malayalammt Maltesemi Maorimr Marathimn Mongolianmy Myanmar (Burmese)ne Nepalino Norwegianps Pashtofa Persianpl Polishpt Portuguesepa Punjabiro Romanianru Russiansm Samoangd Scottish Gaelicsr Serbianst Sesothosn Shonasd Sindhisi Sinhalask Slovaksl Slovenianso Somalies Spanishsu Sudanesesw Swahilisv Swedishtg Tajikta Tamilte Teluguth Thaitr Turkishuk Ukrainianur Urduuz Uzbekvi Vietnamesecy Welshxh Xhosayi Yiddishyo Yorubazu Zulu
01225 316199 [email protected]
Mini Cart 0

Your cart is empty.

Bath Mind
Bath Mind
Get Help Now Donate Jobs Blog
  • Home
  • About Us
    • Vision, Mission and Values
    • Strategy
    • Impact Report
    • Our Ambassadors
    • Trustees and Governance
    • Privacy policy
    • Mind Retail
  • Our Services
    • 1:1 Mental Health Support
      • Access Community Mental Health
      • Befriending
      • Counselling
    • Evening Support: Breathing Space
    • For Professionals
    • Supported Housing
      • Residential Care Home
      • Supported Living
    • Wellbeing Groups
      • Eco-Therapy: Greenlinks
      • Food for Thought
      • Football Group
      • Hopespace
      • Radstock Wellbeing Group
      • Online Wellbeing Group
      • Open Opportunities
      • Photography Groups
      • Movement for Wellbeing: Over 55s Sessions
      • Stitch
      • Wellbeing Walks
    • Supported Living
      • Community Support Service
      • Intensive Outreach Support Service
      • Welfare Benefit Service
    • Support for Young People
      • Mentoring for Young People
      • Room 627
      • Safe Space Group
  • Get involved
    • Events
    • Members Panel
    • Work for Us
    • Volunteering
    • Your Stories Blog
  • Support Us
    • Donate
    • Fundraise for Bath Mind
      • Fundraising at home
      • Fundraising Challenges
    • Bath Half 2022
    • Charity of the Year
    • Gifts in Wills
    • In Memory Donations
    • Our Fundraisers
    • 365 Days of Messages
  • Resources
    • Information and Tips
      • Children and Young People
      • Coronavirus and Mental Health
      • Food and Mood
      • LGBTQI+ Mental Health
      • Loneliness
      • Managing Stress
      • Sport and Mental Health
      • Sleep Problems
      • Wellbeing at Work
    • Local Support Services
      • Get Help Now
      • Community Wellbeing Hub
    • Online Wellbeing Courses
      • Connect with Nature
      • Nutrition for Wellbeing
      • Ways to Wellbeing
    • Wellbeing Activities
      • Armchair Travel
      • Breathing Exercises
      • Colouring for Relaxation
      • Craft Activities
      • Gardening
      • Nature
      • Puzzles, Games & Quizzes
      • Recipes & Nutrition
      • Physical Wellbeing
  • Training
    • Wellbeing in the Workplace
      • Book your session
    • Courses and Qualifications
      • Mental Health First Aid
      • Suicide First Aid
      • Upcoming Courses
    • Training for Young People
  • News
    • Blog
  • Shop
    • Bath Mind Annual Calendar
    • Bath Mind Running Vest
  • Contact us
Login
My Account
0 items
Get Help Now Donate Jobs Blog
  • Home
  • About Us
    • Vision, Mission and Values
    • Strategy
    • Impact Report
    • Our Ambassadors
    • Trustees and Governance
    • Privacy policy
    • Mind Retail
  • Our Services
    • 1:1 Mental Health Support
      • Access Community Mental Health
      • Befriending
      • Counselling
    • Evening Support: Breathing Space
    • For Professionals
    • Supported Housing
      • Residential Care Home
      • Supported Living
    • Wellbeing Groups
      • Eco-Therapy: Greenlinks
      • Food for Thought
      • Football Group
      • Hopespace
      • Radstock Wellbeing Group
      • Online Wellbeing Group
      • Open Opportunities
      • Photography Groups
      • Movement for Wellbeing: Over 55s Sessions
      • Stitch
      • Wellbeing Walks
    • Supported Living
      • Community Support Service
      • Intensive Outreach Support Service
      • Welfare Benefit Service
    • Support for Young People
      • Mentoring for Young People
      • Room 627
      • Safe Space Group
  • Get involved
    • Events
    • Members Panel
    • Work for Us
    • Volunteering
    • Your Stories Blog
  • Support Us
    • Donate
    • Fundraise for Bath Mind
      • Fundraising at home
      • Fundraising Challenges
    • Bath Half 2022
    • Charity of the Year
    • Gifts in Wills
    • In Memory Donations
    • Our Fundraisers
    • 365 Days of Messages
  • Resources
    • Information and Tips
      • Children and Young People
      • Coronavirus and Mental Health
      • Food and Mood
      • LGBTQI+ Mental Health
      • Loneliness
      • Managing Stress
      • Sport and Mental Health
      • Sleep Problems
      • Wellbeing at Work
    • Local Support Services
      • Get Help Now
      • Community Wellbeing Hub
    • Online Wellbeing Courses
      • Connect with Nature
      • Nutrition for Wellbeing
      • Ways to Wellbeing
    • Wellbeing Activities
      • Armchair Travel
      • Breathing Exercises
      • Colouring for Relaxation
      • Craft Activities
      • Gardening
      • Nature
      • Puzzles, Games & Quizzes
      • Recipes & Nutrition
      • Physical Wellbeing
  • Training
    • Wellbeing in the Workplace
      • Book your session
    • Courses and Qualifications
      • Mental Health First Aid
      • Suicide First Aid
      • Upcoming Courses
    • Training for Young People
  • News
    • Blog
  • Shop
    • Bath Mind Annual Calendar
    • Bath Mind Running Vest
  • Contact us
Bath Mind

10 Westgate Street 
Bath 
BA1 1EQ 

01225 316199
[email protected]
  • Privacy policy

Website Design © 2022 C27 Media Ltd

  1. Home
  2. /
  3. Wellbeing Referral Form

Wellbeing Services
Referral Form

This referral form allows you to tell us about why and how you feel you would like our support, so we know how to best help you.

Please give as much detail as you feel is appropriate, including if you have been given a mental health diagnosis, and whether you agree with this diagnosis.

Emergency Contact Details

GP Details

Referral details

About you

This brief section allows you to tell us about why and how you feel you would like our support, so we know how to best help you. Please give as much detail as you feel is appropriate, including if you have been given a mental health diagnosis, and whether you agree with this diagnosis.

CONFIDENTIALITY & DATA PROTECTION

Bath Mind is committed to maintaining client confidentiality. All information about you is held securely and not shared with anyone outside our organisation without your permission, or unless exceptional circumstances occur. If you wish to see the records we hold about you this can be arranged by request to the Chief Executive Officer of Bath Mind. If we believe there is a risk of harm to you or someone else we will inform the appropriate person (such as your GP or other health professional), but we would always endeavour to discuss this with you in advance.

For further information please view our Privacy Policy

Declaration
I declare that the information provided by me is accurate to the best of my knowledge.

If I choose to go ahead and receive counselling through this service, I hereby authorise Bath Mind to store personal information related to me and the service I receive.

If you are happy to accept the above terms and conditions please tick the following box and click on the button marked submit.

Contact Us

Bath Mind

10 Westgate Street 
Bath 
BA1 1EQ 

01225 316199
[email protected]

Help In A Hurry

  • Contact Us

Get Social

  • Facebook
  • Twitter
  • Instagram
  • Youtube
  • LinkedIn

© 2022 Bath Mind
Registered in England 3531040
Charity No. 1069403

Website Design © 2022 C27 Media Ltd

  • Privacy policy
Mini Cart 0

Your cart is empty.