Mind Time Application - Impact Mental Health

To help us provide you with the right support and ensure that your time spent with us is a positive experience,
we ask that you complete this referral form to the best of your knowledge.
Thank you.

Are you referring someone else?*

If you are referring someone else …

Please tell us about you and your relationship to the person you are about to refer to the YOU Programme.

Your Title*

Your First Name*

Your Surname*

What is your relationship to the person you are referring?*

You have selected "Other"

Please describe your relationship to the person you are referring

Your Organisation, Company or Practice

Your Phone Number

Referrer Email*

Do you have consent from the person you are referring to contact us?*

Yes

No

Please tell us about you

Please give us as much information as you can so we can help as much as possible. All your details and the information you provide will be treated in the strictest confidence.

Tell us about the person you are referring

Please give us as much information as you can so we can help as much as possible. All your details and information and those of the person you are referring will be treated in the strictest confidence.

Name*

Title First Last

Date Of Birth

Address

Street Address Address Line 2 City County Post Code

Email*

Phone Number

What’s the best number to call on?

Hidden

Work Phone

Hidden

Mobile

Is there any other information that you think might be useful?

How did you hear about us?*

Data Protection & Privacy*

Under the Data Protection Act 1998 and the new GDPR regulations, Impact Mental Health Peer Support will not share any information related to you and your health with any third party. However we may disclose your personal data to our partners and funding agencies insofar as reasonably necessary for reporting purposes in line with our contractual obligations. Impact has the right to contact the appropriate person or agency and share such information, if we believe you are in danger of harming others or yourself, or, we believe your ill health is seriously affecting your well-being and possible intervention may be required. If this happens, we will always speak to you first if we can but we ask you for your consent here, to ensure that we act accordingly and in-line with our duty of care and responsibility to your support and well-being at all times. By selecting this box, you hereby consent to Impact Mental Health Peer Support using and storing your information collected through this form purely for the use of providing our service only. Our full privacy policy can be viewed here.

I agree

Would you like us to keep you up to date with news and details on new courses and events?

Yes

If you are referring someone else …

Please tell us about you

Tell us about the person you are referring

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