Active Minds Self-referral
Identity
Forename
Nickname
Surname
DateOfBirth
Day
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2nd
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30th
31st
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
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2013
2012
2011
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1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
Address
Address 1
Address 2
Town
County
Post Code
Demographic
Gender
Please choose a value
(Do not use )Transgender (Do not use)
All Other Gender Identities
Female
Male
Non-binary
Not stated
Prefer not to say
Trans Man
Trans Woman
Ethnicity
Please Select
Asian Other
Black Other
Arab
Asian Bangladeshi
Asian Chinese
Asian Indian
Asian Pakistani
Black British African
Black British Carribean
Mixed Other
Mixed White and Asian
Mixed White and Black African
Mixed White and Black Caribbean
Other ethnic group
Prefer not to say
Unknown
White British
White Gypsy or Irish Traveller
White Irish
White Other
White Roma
Contact
Telephone
Email
Service Related Information
Communication Restrictions?
Please choose a value
Yes
No
Unknown
Additional Notes including access requirements
Other Information
Description of mental health i.e. relapse indicators, triggers
How/where did the person hear about the service?
Another Mind Service
Carers information Centre
SLAM
Croydon JCP
ctrp
Enron review
Friend
gp
Gresham 2 ward
Hear Us
Housing Association
Internet
JCP
lantern hall
MH forum or meeting
off the record
other support worker
Out of Borough Support Agency
Palmer House
Porchlight
Previous use of service
Psychologist IAPT
River House, Bethlem
Self Referral
Social Worker
South London Maudsley
South London YMCA
STR worker
The Maudsley Hospital
TV / Press / Radio
Unknown
Voluntary service
Website
Please give contact details for professional support received
Do you give consent to contact these professionals?
Yes
No
Is there any additional support you require?
The last 3 months, have you had any support for mental health?
GP
Supported housing
Probation service
Community treatment team
Care Coordinator
Drug or alcohol services
Social Services
Other Mind Service
MHPIC
Other
None of the above
Consent
Consent to Receive Further Communication?
Please choose a value
Yes
No
Unknown
Health questions
Has your doctor ever said you have a heart condition?
no
yes
Do you ever get chest pains?
no
yes
Do you have a bone or joint problem?
no
yes
Do you lose your balance, get dizzy, or ever lost consciousness?
no
yes
Do you take blood pressure medication?
no
yes
Do you have any other condition made worse through activity?
no
yes
If you've ticked yes to any health question, please give details
Submit