Full Address (please add postcode in required box):
Post Code:
Email: (if possible please add your email address, as it allows us an additional contact method)
NHS Number:
National Insurance Number:
Do we need to be aware of any medical conditions you might have? If so what?
Can messages be left on phone/email: Please choose from drop down list... Yes - Both Phone Only Email Only No - Both
If Yes please state brief overview (e.g. Anxiety, Depression, OCD, Bipolar etc..):
If yes, please say what this was:
Are you currently receiving support either from Mind or other agency? If "Yes" please state below:
Any other course:
Ethnicity and diversity information - What ethnic group do you consider yourself to belong to? Please choose from drop down list... White (English, Welsh, Scottish, Northern Irish, British) White (Irish) White (Any other) Mixed (White and Asian) Mixed (Any other) Asian or Asian British (Indian) Asian or Asian British (Pakistani) Asian or Asian British (Bangladeshi) Asian or Asian British (Chinese) Black or Black British (Caribbean) Black or Black British (African) Black or Black British (Any other) Other Ethnic Group (Arab) Asian or Asian British (Any other) Gypsy/Irish Traveller Other ethnic group Does not wish to disclose
Age group: Please choose from drop down list... 18-24 25-34 35-44 45-54 55-64 65-74 Over 75 Does not wish to disclose
Gender: Please choose from drop down list... Male Female Does not wish to disclose Other
If Other please add below:
Sexuality: Please choose from drop down list... Heterosexual Homosexual Lesbian Bi-sexual Does not wish to disclose Other
If Other please add below:
Religion: Please choose from drop down list... Muslim Christian Jewish Buddhist Hindu Sikh None Other Does not wish to disclose
Relationship Status: Please choose from drop down list...... Single Married Civil Partnership Divorced Widowed Co-habiting Does not wish to disclose
Dependant child under 18 that lives with you? Please choose from drop down list...... Yes No Does not wish to disclose
Ex-Armed Forces: Please choose from drop down list...... Yes No Does not wish to disclose
If yes to carer, in receipt of carers allowance? Please choose from drop down list...... Yes No Does not wish to disclose
Young People – Are you a looked after child or Care-Leaver? Please choose from drop down list...... Yes No Does not wish to disclose
Disability (as defined by the Equality Act 2010): Please choose from drop down list...... Yes No Does not wish to disclose
If yes to disability: Please choose from drop down list...... Physical/mobility impairment Sensory Long standing illness or health condition (e.g. cancer, HIV, diabetes) Learning difficulty/disability Other
If yes to disability, in receipt of DLA/PIP/AA? Please choose from drop down list...... Yes No Does not wish to disclose
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:
“for office use only”
