| Adress: | 57c High St, BA4 5AQ, Shepton Mallet |
| Phone: | +44 1749 233115 |
| Website: | Go to site |
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Mind in Somerset, is located in 57c High St, Shepton Mallet, BA4 5AQ, UK Mind in Somerset This will only take a second!”,”number_decimals”:”2″,”is_test_mode”:””,”give_version”:”3.22.0″,”magnific_options”:{“main_class”:”give-modal”,”close_on_bg_click”:false},”form_translation”:{“payment-mode”:”Please select payment mode.”,”give_first”:”Please enter your first name.”,”give_last”:”Please enter your last name.”,”give_email”:”Please enter a valid email address.”,”give_user_login”:”Invalid email address or username.”,”give_user_pass”:”Enter a password.”,”give_user_pass_confirm”:”Enter the password confirmation.”,”give_agree_to_terms”:”You must agree to the terms and conditions.”},”confirm_email_sent_message”:”Please check your email and click on the link to access your complete donation history.”,”ajax_vars”:{“ajaxurl”:”https://www.mindinsomerset.org.uk/wp-admin/admin-ajax.php”,”ajaxNonce”:”7f27449dbc”,”loading”:”Loading”,”select_option”:”Please select an option”,”default_gateway”:”stripe”,”permalinks”:”1″,”number_decimals”:2},”cookie_hash”:”56f5aa0e333ac24951a831e7f2eeb02e”,”session_nonce_cookie_name”:”wp-give_session_reset_nonce_56f5aa0e333ac24951a831e7f2eeb02e”,”session_cookie_name”:”wp-give_session_56f5aa0e333ac24951a831e7f2eeb02e”,”delete_session_nonce_cookie”:”0″}; /* */ /* */ /* */ /* */ /* */ .woocommerce-product-gallery{ opacity: 1 !important; } body { @font-face{font-family:Inter;font-style:normal;font-weight:300 900;font-display:fallback;src:url(‘https://www.mindinsomerset.org.uk/wp-content/plugins/woocommerce/assets/fonts/Inter-VariableFont_slnt,wght.woff2’) format(‘woff2’);font-stretch:normal;} Skip to content 01935 474875 | 01823 334906 | 01278 228269 | 01643 353115 Mind in Somerset Mind in Somerset Referral Form Please enable JavaScript in your browser to complete this form.Client DetailsFull Name *Date of birth *Address *Town *EmailCounty *Postcode *Phone number *Mobile numberIs it OK to leave a message?YesNoReferral typeSelf-referralReferral by another (Organisation, family etc)Referrer nameReferrer phone numberReferrer emailIn case of emergency please contactRelationshipTelephoneIs there anything you need me to do for you if a medical emergency occurs?GP detailsName of GPSurgery addressTelephoneEmailDo you have any other relevant agency in statutory services? Care coordinator, therapist, floating support worker etc.YesNoJob titleName of professionalAddress of professionalTelephone of professionalEmail of professionalReason for referral being madePresenting issuesPlease select the service(s) you are interested inBridgwater Art GroupTaunton Art GroupMinehead Art GroupTaunton Monday Morning Mind CafeYeovil Gardening GroupYeovil Community DayHighbridge and Burnham Wellbeing GroupSomerset Wellbeing FriendsLocal Peer Support GroupsTaunton Wobbly Bus StopTaunton Bridging the GapHearing Voices Support GroupsOpen Mental HealthSomerset Suicide Bereavement Support ServiceRecover and Wellbeing WorkersYouth Matters (11-24)Menopause GroupDon’t KnowHopes for the future and key outcome requiredDiversity Monitoring Data (optional)Ethnic originWhite British or Northern IrishWhite IrishGypsy or Irish TravellerOther White BackgroundBlack or Black BritishAsian or Asian BritishMixed/Multiple Ethnic GroupsOther Ethnic GroupEmployment statusEmployed Full-timeEmployed Part-timeUnemployedSelf-employedEmployed but off work due to ill healthRetired (due to age)Retired (due to ill health)StudentHomemakerVolunteeringLong term illness/unable to workCarerDo you consider yourself to have a disability or long term health condition?YesNoPlease tick all that applyMental health conditionPhysical health conditionLearning disability/difficultyDevelopmental disabilityBehavioural disability e.g. AspergerDeafness / Partial loss of hearingBlindness / Partial loss of sightWhat is your religion/belief?ChristianBuddhistHinduJewishMuslimSikhHumanistNo religionOtherDo you consider where you live to beUrbanSemi-urbanRuralWhat is your accommodation status?Own homeSocial housingPrivate tenantHomelessSupported housingWith which gender do you identify?FemaleMaleTransgender FemaleTransgender MaleGender Variant/Non-ConformingPrefer Not to AnswerSexual orientationHeterosexualBisexualLesbianGayOtherPrefer not to sayGDPR/Data Protection Privacy Notice | |
