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Referrer details

*If you are self-referring please skip this section and complete from the beginning of the next section*
Name

Applicant Details

Name
Preferred method of contact
Borough
Sexual orientation
Gender Identity
Current Employment Status

Ethnicity and Diversity

Ethnicity
Religion

Health Questionnaire

Do you have any known risks?
Click or drag a file to this area to upload.
If you do not have a criminal record, please put N/A
Do you have a disibility
Do you have any medical or health conditions?

GP Details

GP Name

Emergency Contact Details

Name

Informed Consent

West Central London Mind will keep basic information about you on our databases so we can track your progress through our service(s) and contact you when necessary. In addition we will hold a written record of your contact with us. These records will be kept in line with West Central London Mind’s guidelines, and in compliance with the General Data Protection Requirements 2018.

Consent to hold and store information

I would like to subscribe to the West Central London Mind newsletter and communications.
I agree to give permission to West Central London Mind to keep written details relating of my contact with them and to hold information on its database(s). I understand this information is required in order to provide the service to me and that without this information I may not be able to receive the service.
I agree to give consent for West Central London Mind to keep records about me both electronically and in hard copy.
I agree to give my consent for West Central London Mind Mind to hold information on appropriate databases and written details of my contact with them. I understand that access to this information may be provided to the relevant London Boroughs Commissioning group if requested.

Consent to obtain information

I agree to give my consent for West Central London Mind to contact relevant agencies to gather information about me (including copies of correspondence and reports) from relevant organisations such as: GP, Adults Mental Health, psychiatric services, Recovery team and other statutory professionals involved in my care, Police, Forensic & emergency services, Brent Council, Westminster City Council or Wandsworth Council, Utilities Companies, DWP, Social Security, Housing Benefits Job Centre Plus

Consent to share/pass information

I agree to give my consent for West Central London Mind to contact relevant agencies to Mind to share information about me with the following organisations: GP, Adults Mental Health, psychiatric services, Recovery team and other statutory professionals involved in my care, Police, Forensic & emergency services, Brent Council, Westminster City Council or Wandsworth Council, Utilities Companies, DWP, Social Security, Housing Benefits Job Centre Plus

Consent for photographs and videos

I agree to give my consent for West Central London Mind to use any photographs or video of myself for the following purposes:
*For use on all marketing activity such as the charity’s printed annual reports, leaflets or any publicity material and in events exhibitions/ conferences, on the charity’s websites, as display work at the charity’s events, training or conferences*

Consent for story telling

I agree to give my consent for West Central London Mind to use my anonymised story/case study
*For use on printed annual reports, leaflets or any publicity material, and in events/exhibitions, on the charities websites, share with commissioning agencies.

Consent to use my Photography, film, music and/or any artwork

I agree to give my consent for West Central London Mind to use any photographs, films, music and/or any original artwork I may produce
*For use on the charity’s printed annual reports, leaflets or any publicity material and in events exhibitions/ conferences, training etc, on the charity’s websites, as display work at the charity’s events, training or conferences
I understand that West Central London Mind may in future sell any donated artwork and that all proceeds will go to the charity.
I would like to have any of my work credited to me

General Privacy and Understanding

I understand that West Central London Mind will act in accordance with the General Data Protection Regulations 2018 and will only share information on a need-to-know basis. I further understand that there are specific and limited exceptions to this confidentiality which include the following: When there is risk of imminent danger to myself or to another person, the practitioner/organisation is ethically bound to take necessary steps to prevent such danger. When there is suspicion that a child or adult is being sexually, physically, emotionally abused or neglected, or is at risk of such abuse, the practitioner/ organisation is legally required to take steps to protect the vulnerable adult or child, and to inform the relevant authorities. When a valid court order is issued for case records, the practitioner and the organisation are bound by law to comply with such requests.

I understand that I can

Clear Signature
Withdraw my consent to any of the above at any time; Request details of the information West Central London Mind hold of me; Request West Central London Mind to remove data they hold of me.
Name