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:
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..):
Do we need to be aware of any medical conditions you might have? If so what?
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:
GP Surgery: Please choose from drop down list...... Hoo St Werburgh Medical Practice (PL) Balmoral Gardens Clinic (PL) Highparks Medical Practice (PL) The Elms Medical Centre (PL) The Medical Centre Gun Lane (PL) Court View Surgery (PL) Marlowe Park Medical Centre (PL) Apex Medical Centre Gun Lane (PL) Castle Medical Practice (PL) The Dame Sybil Thorndike (PL) Borstal Village Surgery (PL) Glebe Family Practice (ST) Malvern Road Surgery - Medway Medical Centre (ST) Napier Road Surgery (ST) Pump Lane (ST) Upper Canterbury Street (ST) Woodlands Family Practice (ST) Railside Surgery (ST) Railway Street Surgery (ST) Church View Practice (ST) Church View Practice (ST) Long Catlis Road Surgery (ST) Maidstone Road Surgery (The Surgery) (ST) Matrix Medical Centre (ST) Orchard Family Practice (ST) Parkwood Family Practice (ST) Thames Avenue (ST) Wigmore Medical Centre (ST) Luton Medical Centre (ST) Parkwood Health Centre (ST) Waltham Road (ST) King George Road Surgery (ST) Maidstone Road Chatham Surgery (ST) Princes Park Medical Centre (ST) Reach Healthcare (ST) Stonecross and West Drive Surgery (ST) St Mary’s Medical Practice The Churchill Clinic (ST) Tunbury Avenue Surgery (ST) Wayfield Road Surgery (ST) If Other please enter in the box below:
Other GP Surgery (please note GP location is required to determine course availability):
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:
Relationship Status: Please choose from drop down list...... Single Married Civil Partnership Divorced Widowed Co-habiting Does not wish to disclose
Religion: Please choose from drop down list... Muslim Christian Jewish Buddhist Hindu Sikh None Other 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
Are you a carer? 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
Ex-Armed Forces: Please choose from drop down list...... Yes No Does not wish to disclose
If Other please add below:
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”