General registration form

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Phone Number *

(###)

###

####

How would you prefer to be contacted? *

By phone

By email

Either is fine

Do you have any communication needs we may need to know about? *

For example, you're hard of hearing or have difficulty reading emails, etc.

Yes

No

Do you have a current mental health diagnosis? *

For example, depression, anxiety, bipolar, etc.

Yes

No

Are you currently using any other mental health services? *

For example, private counselling, other support groups, etc.

Yes

No

Where did you hear about our services? *

Community mental health team

Devon Mind letter/email

Devon Mind social media

Devon Mind website

GP/other medical professional

Plymouth Options

TALKWORKS

Word of mouth/recommendation

Don't know/can't remember

We require your explicit consent to process this data because it contains details about your health. We ask you to provide this information so that we can provide you with the correct support for your needs. We will process your data in accordance with our Privacy Policy, which is available at www.devonmind.com/privacy. Please check the box below to confirm your consent. *

I give my explicit consent for you to process my health data

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