01208 892 855

Referral to Cornwall Mind

All fields marked with * are mandatory

We encourage self referral. If you are a professional making a referral on behalf of someone else, please let us have your contact details in the box below. Thank you.
We encourage self referral. If you are a professional making a referral on behalf of someone else, please let us have your contact details in the box below. Thank you.
Name
Organisation
Email and phone number
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.
Address
Address
Postal Town
County
Postcode
We are currently taking referrals for the following:
If you know which service you would like, please tick box(es) below
Data protection permission
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.
Which of these categories best represents your experience of mental health problems? (Please tick all that apply)
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