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Please provide as much information as possible to enable us to support you effectively.

At least one contact method must be provided in order for us to be able to contact you regarding your request.

If you have any issues or enquiries when completing this form please contact our HQ offices on 0300 330 0648 or hq@mind-blmk.org.uk.

Your Details

Title

Forename

Preferred Name

Surname

Date Of Birth

Gender

Is your gender the same as the gender you were assigned at birth?

Preferred Pronouns

Ethnicity

If other, please specify

Address

Address 1

Address 2

Town

County

Post Code

Emergency Contact

Name

Telephone Number

Relationship

Has emergency contact given consent to be contacted in emergency?

GP Details (if known)

Name

GP Address

Postcode

GP Telephone

Equal Opportunities and Disability Monitoring

Is there anything that you need from us to ease your access to the service?

If yes, please provide a brief description

Do you have any medical conditions we may need to know about in an emergency (e.g. epilepsy, diabetes, allergies or asthma)? Do you carry any medications with you for these conditions?

SUN only accepts self-membership requests.

Did you complete the membership request yourself?

Do you identify as struggling with complex emotional needs most commonly associated with personality disorders? Those accessing SUN groups may typically experience a range of longstanding challenges including: Difficulty managing intense emotions, uncertainty about who you are and/or your direction in life, lots of ups and downs in your relationships with others, frequent feelings of emptiness and loneliness, intense fear of abandonment, impulsivity and self-destructive behaviours (e.g. enduring suicidal thoughts, self-harm, addiction, gambling etc.).

Consent

Data Protection & Confidentiality