Title*
Address line 2
Postcode
Can we leave voice messages?*
Date of Birth*
Gender*
Please note that if you are receiving support from the NHS services a risk assessment will be required from a Mental Health Team or Adult Care Services. If you are a professional supporting someone to complete this form please attach a risk assessment. If you have a copy of your own risk assessment please do let us know and bring it with you to your first consultation.
GP Name
We provide the following services. Please tick the ones you are interested in. [Please note that a small charge is made for most services.]
We have centres in the following locations. Please tick all the locations you are interested in:
(PLEASE NOTE THAT NOT ALL SERVICES ARE AVAILABLE IN ALL OUR CENTRES.)
Our commitment to you
We will always respect your personal information and privacy.
All information which is shared is confidential, subject to the following conditions:
- All staff working at Mind in Mid Herts are required to have supervision for ongoing professional development. Individual cases and information might be discussed as part of this process, but service users’ anonymity will be protected at all times.
- Project Officers have access to service users’ files to monitor and report on the services.
- Staff and volunteers are not permitted to keep secrets. They are bound by a duty of care to share any information which might give any cause for concern.
Your Rights
To comply with the new regulation we have procedures and technologies in place so by making a written request you can exercise your:
Right to be informed about how we collect and use your information.
Right of access : We have an ‘open file’ process which enables you to access all your records whenever you wish.
Right to rectification and data quality : We will ensure that the personal data we hold remains up-to-date and accurate.
Right to erasure : We have processes in place to securely dispose of personal data that is no longer required, or where you have asked for it to be erased. However, please note that Mind in Mid Herts is subject to laws governing retention periods.
Right to object to the use of your personal data : We will not use your data for direct marketing without your positive consent. You also have the right to restrict our processing of your data while we address any objection you raise.
Right to data portability : We will provide your data to a new or additional service provider if you so wish.
How would you like us to contact you to progress this referral? [Please indicate all the ways you would like us to contact you.]
Contact by telephone
Contact by email
Contact by text/SMS
Contact by post
Please note that you can change or withdraw your consents at any time.
Service User declaration: The details I have given are accurate. I give my permission for Mind in Mid Herts to obtain information if required (including risk assessments) from other agencies which currently support me, both statutory and charity sector.