Home » What we offer » Adult Services » Adult Groups » Register your interestAdult Groups Register Your Interest If you would like to register your interest in one of our groups then please fill out the form below by selecting which group you would like from the drop down. Please enable JavaScript in your browser to complete this form.1About You2Health and wellbeing information 3Equality & Diversity4Declaration Which group are you registering for? *Active in MindMindOut LGBTQ+Women in MindWellbeing in MindName *FirstLastAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodePhone *LayoutCan we leave a voicemail?YesNoCan we text?YesNoEmail *Preferred method of contactPhone CallEmailTextDate of birth *How did you hear about Dorset Mind? NextWhich GP Practice are you registered with? Do you consider yourself to have a long term health condition or learning difference / special educational need that has a substantial impact on your ability to carry out day to day activities? Examples may include epilepsy, depression, Autism Spectrum Disorder (ASD), or deafness. YesNoPrefer not to sayPlease describe your health condition or learning difference below. Which of these categories best represents your experience of mental health problems? (Please tick all that apply) I have personal experience of mental health problemsI use / have used mental health servicesI am a family member of somebody who has experienced mental health problemsI am a friend to someone who has experienced mental health problemsI care or look after someone who has mental health problemsAnotherNone of the abovePrefer not to sayAnother - Please specify if you wishPlease state a little about why you are wanting to access this Dorset Mind group? How can we support you? *PreviousNextWe 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. What is your gender? *MaleFemaleNon-binaryPrefer not to sayAnother/prefer to self-describePlease give detailsHave you ever identified as trans? YesNoPrefer not to sayRelationship statusMarriedSingleIn a relationshipEngagedDivorcedWidowedWhat is your sexual orientation? BisexualGay/LesbianHeterosexual/StraightPansexualAsexualPrefer not to sayUnsureAnother/prefer to self-describePlease give detailsAre you a carer? YesNoPrefer not to sayHow would you describe your ethnic background? LayoutAsian or Asian British BangladeshiChineseJapaneseIndianPakistaniAnother Asian backgroundBlack or Black British AfricanCaribbeanAnother Black backgroundOther ethnic group ArabGypsy or TravellerAnother backgroundMixed Asian & WhiteBlack African & WhiteBlack Caribbean & WhiteAnother mixed backgroundWhite or White British British / English / Welsh / Scottish / Northern IrishIrishEastern EuropeanAnother white backgroundWhat is your religion or belief? First ChoiceAgnosticAtheistChristian (includes all denominations)BuddhistHinduJewishMuslimSikhNo religionAnother / prefer to self-describePrefer not to sayPlease give detailsWhat is your preferred language? PreviousNextWe need your permission to support you & communicate with you. By consenting below you are agreeing to the terms of our Privacy Policy GDPR Agreement *I consent to Dorset Mind holding and processing my data I am happy for Dorset Mind to contact me with news, information and requests of support YesNoSigned *Date *Submit
