Referral to Cornwall Mind

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.

Last name

First name

Date of birth

Address

Postal Town

County

Postcode

Email

Phone

Reason for referral

We are currently taking referrals for the following:

If you know which service you would like, please tick box(es) below

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: [email protected]

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?

Have you ever identified as trans?

What is your sexual orientation?

What is your ethnic background?

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?

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

Where did you hear about Cornwall Mind?

01208 892 855

Get in Touch