Therapies Registration

About You

First Name*
Last Name*
Date of Birth*
Gender* —Please choose an option—MaleFemaleNonbinaryNot specifiedOther (not listed)Other Prefer Not to Say
Is your gender the same as it was at birth?*
—Please choose an option—YesNoNot statedOther Prefer Not to Say

Nationality* —Please choose an option—BritishEnglishWelshScottishNorthern IrishIrishAfghanAlbanianAlgerianAmericanAndorranAngolanAnguillaAntigua & BarbudaArgentineArmenianAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBelarusianBelgianBelizeanBenineseBermudianBhutaneseBolivianBosnia & HerzegovinaBotswananBrazilianBritish Virgin IslanderBruneianBulgarianBurkinanBurmeseBurundianCambodianCameroonianCanadianCape VerdeanCayman IslanderCentral AfricanChadianChileanChineseColombianComoran Congolese (Congo)Congolese (DRC)Cook IslanderCosta RicanCroatianCubanCymraesCymroCypriotCzechDanishDjiboutianDominicanDominican RepublicDutchEast TimoreseEcuadoreanEgyptianEmiratiEquatorial GuineanEritreanEstonianEthiopianFaroeseFijianFilipinoFinnishFrenchGaboneseGambianGeorgianGermanGhanaianGibraltarianGreekGreenlandicGrenadianGuamanianGuatemalanCitizen of Guinea-BissauGuineanGuyaneseHaitianHonduranHong KongerHungarianIcelandicIndianIndonesianIranianIraqiIsraeliItalianIvorianJamaicanJapaneseJordanianKazakhKenyanKittitianCitizen of KiribatiKosovanKuwaitiKyrgyzLaoLatvianLebaneseLiberianLibyanLiechtenstein citizenLithuanianLuxembourgerMacaneseMacedonianMalagasyMalawianMalaysianMaldivianMalianMalteseMarshalleseMartiniquaisMauritanianMauritianMexicanMicronesianMoldovanMonegasqueMongolianMontenegrinMontserratianMoroccanMosothoMozambicanNamibianNauruanNepaleseNew ZealanderNicaraguanNigerianNigerienNiueanNorth KoreanNorwegianOmaniPakistaniPalauanPalestinianPanamanianPapuaNew GuineanParaguayanPeruvianPitcairn IslanderPolishPortuguesePrydeinigPuerto RicanQatariRomanianRussianRwandanSalvadoreanSammarineseSamoanSao TomeanSaudi ArabianSenegaleseSerbianCitizen of SeychellesSierra LeoneanSingaporeanSlovakSlovenianSolomon IslanderSomaliSouth AfricanSouth KoreanSouth SudaneseSpanishSri LankanSt HelenianSt LucianSudaneseSurinameseSwaziSwedishSwissSyrianTaiwaneseTajikTanzanianThaiTogoleseTonganTrinidadianTristanianTunisianTurkishTurkmenTurks & Caicos IslanderTuvaluanUgandanUkrainianUruguayanUzbekVatican citizenCitizen of VanuatuVenezuelanVietnameseVincentianWallisianYemeniZambianZimbabweanNot ListedPrefer Not to Say

Ethnicity —Please choose an option—White BritishBlack BritishAsian BritishMixed Race BritishWhite Non-BritishBlack Non - BritishAsian Non-BritishMixed Race Non -BritishOtherPrefer Not to Say

Religion—Please choose an option—ChristianBuddhistHinduJewishMuslimSikhOtherNo ReligionPrefer Not to Say

Sexual Orientation
—Please choose an option—HeterosexualGay or LesbianBisexualPansexualAsexualQueerOtherPrefer Not to Say
Have you ever been in the Armed Services?YesNoPrefer Not to Say

Mental Health Support

Are you currently or have you previously received any support from mental health services? YesNo
If yes, please provide details
Please give a brief understanding of what has brought you to seek further support from Lancashire Mind at this time*
Please tick the relevant boxes that apply to your current mental health:
AnxietyPanicLow mood/DepressionTraumaObsessive Compulsive DisorderSpecific fear or phobiaBereavementPoor SleepStressOther
Do you have a preference of therapy option?
CounsellingCBTWellbeing Coaching

Contact Details

Address*
Postcode*
Contact Number*
Email*
Preferred Contact Method* —Please choose an option—EmailPhone
Preferred Contact Time*—Please choose an option—MorningAfternoon
Next of Kin: Name*
Next of Kin: Contact Number*
Next of Kin: Relationship to You*
Can we contact you to ask for your feedback?Yes

We would like to contact you to ask for feedback about your experience of our service. This will help us to continuously improve our services

Medical

Please note, we would only contact your GP in the event of an emergency.

GP Practice Name*
GP Practice Contact Number*
Do you consider yourself to have a disability?* YesNoPrefer Not to Say
Do you have a long term medical condition?* YesNoPrefer Not to Say
If yes, please provide details
Are there any reasonable adjustments to support your access to the service we need to be aware of?

Next Steps

After submitting this form: someone from our Therapeutic services team will contact you via phone to book in your personal wellbeing assessment within the next 5 working days. This call will take approximately 30- 45 minutes and we will use this time to explore in more detail your current problems. We would request that for this call you are somewhere you will not be disturbed and can speak freely.

Following the call, we will recommend the most appropriate route for you and will let you know the current wait times to see a therapist. If your needs can’t be met by Lancashire Mind’s Therapies service, we will signpost you to alternative support.

I confirm my consent for Lancashire Mind to collect my data in line with the Privacy Policy.*Yes

We collect personal and sensitive data in order to ensure our services meet your needs. Please refer to our Privacy Policy for full details of how we store and process your personal and sensitive data.

Would you like to receive news, events and service updates from Lancashire Mind?Yes