Men in Mind - Referral Form

Dorset Mind adult groups offer support to adults over 18 years of age, experiencing mild to moderate mental health issues and our groups will not be suitable for anyone who is currently experiencing any of the following: Suicidal ideation; recent suicide attempts; a recent psychotic episode or recent addiction of any sort. Therefore, before you proceed with the registration form, you will need to answer 'Yes' to all the statements below (please tick the box to indicate this). If your answer is 'No' to any of these statements, you should not complete the registration form.

If you require support for any of these issues you can refer to our signposting list under 'What We Offer > Resources' or please contact your GP for guidance.

Please proceed if you can answer YES to the following questions,

I can confirm that I do not suffer from addiction or - that if I have suffered from addiction of any sort - I have been abstinent for 3 months or more.
I can confirm that I have not experienced a psychotic episode or +that - if I have, - I have been stable for a minimum of 6 months or more.
I have not attempted suicide within the last 6 months.
I have no current suicide ideation or plans to harm myself.
I want to access support in a group environment and I am willing to engage with peers.

Please tick the box below to confirm and proceed

I can answer YES to all of the above questions

Name

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone

Layout

Can we leave a voicemail?

Yes
No

Can we text?

Yes
No

Email

Preferred method of contact

Phone Call
Email
Text

Select all that apply

How did you hear about us?

Which GP Practice are you registered with?

Do you consider yourself to have a disability?

Yes
No

Do you have any health conditions we should be aware of?

Yes
No

Please tell us about your current mental health and emotional wellbeing needs

What would you like to get from coming to this programme?

We won’t give up until everyone experiencing a mental health problem gets both support and respect. 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 only be shared anonymously. Thanks for your help.

Date of Birth

How would you describe your ethnic background? 

We need your permission to support you & communicate with you. By consenting below you are agreeing to the terms of our Privacy Policy

I am happy for Dorset Mind to contact me with news, information and requests of support 

Yes
No

Signed

Date

Men in Mind: Physical Activity and Wellbeing Group

Men in Mind Referral Form

How would you describe your ethnic background?