This online 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.

To refer via email, please email wellbeing@bathmind.org.uk with a completed Referral Form

Please enable JavaScript in your browser to complete this form.
Have you looked at all the groups we offer, which interests you the most?
Referral made by:
This could be a nickname you prefer, or an additional name you may like to go by.
Address
Please note: we require a telephone number or email address to contact you about your referral. If you don’t wish to share details of both, write 'N/A' in the box that you'd like to leave blank.
Can we contact you by the following means? Please tick all that apply

Information About You

Gender
Your Pronouns
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.
How would you describe your relationship status?
What is your employment status?
If so, which ones?
If so, please describe your disability. You may select more than one.
What is the main reason you have for coming to a group? (please tick one)

Information about your GP/Surgery

Emergency Contact Details

Would you like to sign up to receive monthly updates from Bath Mind including wellbeing tips, upcoming events and courses, and charity news?

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 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.

Single Checkbox Field