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

for better mental health

North Kent Mind – Digital 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 support.

If you live in the Dartford, Gravesham, Swanley areas (if you live in the Medway area, please click here), please complete the form below.

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

“for office use only”

GDPR *

Privacy Promise

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

Website

North Kent Mind Privacy Policy
North Kent Mind – Service-Users Code of Conduct
LiveWell Kent Partners Privacy Promise
Information on how to find your NHS Number

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We work to ensure that no-one faces a mental health problem alone and to promote better mental health understating in the community.

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North Kent Mind relies on public support from events, donations and gifts in wills to provide high quality mental health services to anyone that needs us.

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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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