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North Kent Mind

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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. Please note * is a required field.

First Name: *

Last Name: *

Date of Birth: *

Address:

Phone Number: *

Email: *

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:

Please tell us which group/activities (online) you would like to attend

Coping With Life
Peer Support Group
Young Person's Peer Support Group (17-25)
Peer Support Coffee Morning
Computer Group
Mindfulness
Employment Support
Young Person’s Emotional Wellbeing Workshops
Aspirations
SilverCloud (Cognitive Behavioural Therapy)
Other

If Other please state:

Would you like to receive Individual Support

Yes
No
Not Sure

If available would you consider attending evening (6-8pm via ZOOM) Coping with Life courses?

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

Age group:

Gender:

Sexuality:

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

GDPR *

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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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