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Volunteer for us
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01208 892 855
Mind Cornwall — for better mental health
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Referral to Cornwall Mind
Referral to Cornwall Mind
Referral to Cornwall Mind
All fields marked with * are mandatory
Difficulties accessing this form?
If you have any difficulties accessing this form, please call 01208 892855 and leave a message with your name and contact details and we will call you back.
Last name
*
First name
*
Date of birth
*
Address
*
Address
Address
Address
Postal Town
Postal Town
County
County
Postcode
Postcode
Email
*
Phone
*
Reason for referral
*
If you know which service you would like, please tick box(es) below
*
5 Ways to Wellbeing Workshop – Various locations
Gardening Group – Bodmin
Allotment Group – Falmouth
Walking Group – Newquay
Art Group – Newquay
Music Group – Bodmin
Music In Mind – Truro
Singing for Wellbeing (For those bereaved through suicide) – Camborne
Sing For Joy (Open to all) – Camborne
Hope Walks (For those bereaved through suicide) – Various Locations
Eco Action – Various Locations
Cafe and Chat – Online
Radio and Podcasting – Falmouth
Hearing Voices (For those experiencing voices) – Bodmin and Penzance
Peer Recovery Group – St Austell
Peer Recovery Group – Newquay
Peer Recovery Group – Looe
Peer Recovery Group – Liskeard
Not sure, please contact me to discuss
Not sure, please contact me to discuss
Data protection permission
*
Yes
In view of the way we process and store your data in compliance with General Data Protection Regulation (GDPR), it is essential we have your permission. We take your privacy seriously and promise to never sell your data. You can find out more about your rights, how we keep your personal information and how we keep your details safe and secure by reading our Privacy Policy, which can be accessed through our website or by contacting the office. For more information, or to withdraw your consent to us processing your data, contact the office on 01208 892855 or email: info@cornwallmind.org
Equality and Diversity Monitoring (Optional)
We want to know a bit more about you, to understand who we are engaging with our work, and who we need to work harder to reach. We also want to make sure we understand the needs of all the communities we work with. Completing these questions is voluntary, and the information you provide will be entirely anonymous. Thanks for your help.
What is your gender?
Please select
Female
Male
Non-binary
Another/prefer to self-describe
I prefer not to say
Have you ever identified as trans?
Please select
Yes
No
What is your sexual orientation?
Please select
Gay/lesbian
Heterosexual/straight
Another/prefer to self-describe
I prefer not to say
What is your ethnic background?
Please select
White
Asian
Black
Mixed heritage
Another/prefer to self-describe
I prefer not to say
Do you consider yourself to have a long term health condition or learning difference that has a substantial or long term impact on your ability to carry out day to day activities?
Please select
Yes
No
I prefer not to say
Which of these categories best represents your experience of mental health problems? (Please tick all that apply)
*
I have personal experience of mental health problems
I use/have used mental health services
I am a family member of somebody who has experienced mental health problems
I am a friend to someone who has experienced mental health problems
I care for or look after someone who has mental health problems
Another (please specify if you wish)
Another (please specify if you wish)
None of the above
If you are human, leave this field blank.
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