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Referrer details

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

Applicant Details

Ethnicity and Diversity

Health Questionnaire

Click or drag a file to this area to upload.
If you do not have a criminal record, please put N/A

GP Details

Emergency Contact Details

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

Consent to obtain information

Consent to share/pass information

Consent for photographs and videos

*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

*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

*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

General Privacy and Understanding

I understand that I can

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