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

Please note * is a required field and the course/group support list shown below (Please tell us what support would you like to access: section) availability is dependent on your doctors geographical location.

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..):

Do we need to be aware of any medical conditions you might have? If so what?

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 Note: Our CWL and Mindfulness courses both run in-person and via Zoom. Would you prefer:

In-person courses run between 10:00-15:00
Zoom courses run after 18:00

Any other course:

GP Surgery:

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?

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 are there people you can trust? *

How safe do you feel where you live? *

Do you struggle to get where you want to go due to local transport problems? *

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? *

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).

Website

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.