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- Dartford, Gravsend, Swanley Areas
- Medway Area
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North Kent Mind

for better mental health

Men’s Group

North Kent Mind – Men’s Group

Registration Form

North Kent Mind is a registered charity (No1103790), who offer individuals who have previously suffered or currently suffering from a Mental Health issue suppor: Our Men’s Group offers peer support for individuals a safe space (via Zoom) to connect with others through conversation, mindful activities and shared interests.

Please note is a required field.

Please select your location: *

First Name: *

Last Name: *

Date of Birth: *

Full Address (please add postcode in required box):

Post Code:

Phone Number: *

Email: (if possible please add your email address, as it allows us an additional contact method)

NHS Number:

National Insurance Number:

Call availability: When can we call you?

Mornings
Afternoons
Evenings

Can messages be left on phone/email:

Have you previously suffered or currently suffering from a Mental Health issue

Yes
No
Unsure

If Yes please state brief overview (e.g. Anxiety, Depression, OCD, Bipolar etc..):

Are you currently receiving support either from Mind or other agency? If "Yes" please state below:

Please tell us what support would you like to access:

Individual Wellbeing Support (via telephone, email or Zoom)
Coping With Life (via Zoom)
Peer Support Group (via Zoom)
Young Person's Peer Support Group - Age 17-25 (via Zoom)
Peer Support Coffee Morning (via Zoom)
Computer Group (Via Zoom)
Mindfulness (via Zoom)
Employment Support (via telephone, email, Zoom)
Men's Group
Young Person’s Emotional Wellbeing Workshops- Age 17-25 (via Zoom)
Aspirations (via telephone, email, Zoom)
Friendship Group (Saturdays via Zoom)
Other (please use box below)

Any other course:

Economic Status:

Full-time student
Full-time work >24hrs/wk
Part-time work < 24hrs/wk
Job seeker
Not seeking work
Other adult
Does not wish to disclose

Ethnicity and diversity information - What ethnic group do you consider yourself to belong to?

Age group:

Gender:

If Other please add below:

Sexuality:

If Other please add below:

Religion:

How did you hear of North Kent Mind services?

What is your goal when using North Kent Mind Services? *

Emergency Contact: *

Emergency Contact Relationship to you:

Emergency Contact Phone Number: *

Below are some statements about feelings and thoughts. Please select what best describes your experience over the last 2 weeks:

I’ve been feeling optimistic about the future

1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time

I’ve been feeling useful

1. None of the time
2. Rarely
3. Some of the time
4. Often
All of the time

I’ve been feeling relaxed

1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time

I’ve been dealing with problems well

1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time

I’ve been thinking clearly

1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time

I’ve been feeling close to other people

1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time

I’ve been able to make my own mind up about things

1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time

My accommodation has a positive effect on my health

1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time

I access the things I want to do in my Community

1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time

I feel safe where I live

1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time

I understand my health needs and do the things that keep me well

1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time

I take care of myself and my home

1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time

I want to work

1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time

I manage my money well

1. None of the time
2. Rarely
3. Some of the time
4. Often
5. All of the time

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By ticking this box I agree to North Kent Mind's & LiveWell Kent Partner Privacy Promise (links below to policies).

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North Kent Mind Privacy Policy
North Kent Mind – Service-Users Code of Conduct
LiveWell Kent Partners Privacy Promise
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North Kent Mind

The Almshouses | 20 West Hill, Dartford | DA1 2EP
Phone: 01322 291380
Email: admin@northkentmind.co.uk
Website: https://northkentmind.co.uk
Registered In England company No.5093370
Limited by Guarantee Registered Charity No.1103790

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