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.