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This referral form allows you to tell us about why and how you feel you would like our support so that we know how to best help you. Please give as much detail as you feel is appropriate.

This could be a nickname you prefer, or an additional name you may like to go by.

Information About You

Pronouns are used in place of a proper noun (like someone’s name). We use pronouns most often when referring to someone without using their name.

Information about your GP/Surgery

Emergency Contact Details


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

I understand and have read, Bath Minds Privacy Policy. I declare that the information provided by me is accurate to the best of my knowledge.

If I choose to go ahead and access the services provided by Bath Mind, 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.

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