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North Kent Mind

for better mental health

North Kent Mind – Medway Digital Registration Form

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

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.

Please select your location: *

Medway

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..):

Have you ever acted in a way which was seen as threatening, physically abusive or aggressive?

If yes, please say what this was:

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:

Social Skills Session (Saturdays via Zoom)
Coping With Life (via Zoom)
Mindfulness (via Zoom)
Employment Support (via telephone, email, Zoom)
Aspirations (via telephone, email, Zoom)
Activity Session (currently via Zoom)
Friendship Group (currently via Zoom)
Men's Group (currently via Zoom)
Ecology Island
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

GP Surgery:

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:

Relationship Status:

Religion:

Dependant child under 18 that lives with you?

Are you a carer?

If yes to carer, in receipt of carers allowance?

Ex-Armed Forces:

What do you feel may have led to you feeling lonely and isolated? (If more than one issue, which area do you feel affects you the most?) *

If Other please add below:

How much do you agree or disagree with the following statement? If I needed help, there are people who would be there for me? *

How much do you agree or disagree with the following statement? If I wanted company or to socialise, there are people I can call on? *

How often do you chat to your neighbours, more than just to say hello? *

How often to you access things in your local community? *

How strongly do you feel you belong to your immediate neighbourhood? *

Generally speaking, would you say that most people can be trusted, or that you can’t be too careful in dealing with people? *

How safe do you feel where you live? *

How much does access to transport affect you getting around locally? *

Overall, how satisfied or dissatisfied are you with your local area as a place to live? *

How often do you feel that you lack companionship? *

How often do you feel left out? *

How often do you feel isolated from others? *

How often do you feel lonely? *

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
5. 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

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

Emergency Contact: *

Emergency Contact Relationship to you:

Emergency Contact Phone Number: *

“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).

Comment

Policies & NHS Numbers
(Please note all links below will open in a seperate window, already added form data will not be lost):

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

Thank you for your self referral we will be in contact soon and may require some further information.

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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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