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Hertfordshire Mind Network
Hertfordshire Mind Network
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Hertfordshire Mind Network Referral Form

Please complete this form if you would like to access our services and we will contact you to discuss next steps. Please give as much information as possible.

Your Details

Name *
Please tick all the ways that we can use to contact you? ? *
Is it OK for us to leave a message on your mobile?
Do you need an interpreter?

Emergency contact details

In the event of an emergency, who would you like us to contact?

GP Surgery

Employment information

Employment information *

Housing status

Are you homeless, in temporary accommodation, or facing eviction? *
Housing status *

Hospital admission

Have you been discharged from Watford A and E, Lister A&E, Kingfisher Court or Albany Lodge within the last 7 days? *

Further information

Which 1:1 service would you like to access? (If you are unsure of which service you would like to access, please call 0203 727 3600 Mon to Fri 9am - 5pm to discuss) *
If you would like to attend groups and activities, which one(s) interest you? *
How did you hear about us?

Details of referrer

(if completing the form on behalf of someone else)

Equal Opportunities and Disability Monitoring

Age Group *
Gender *
Religion/ faith *
Sexual orientation *
Disability: Are your day-to-day activities limited because of a health problem or disability which has lasted or expecting to last for at least 12 months? *
Ethnicity *
Caring responsibilities
Relationship status
Autism

Data Protection and Confidentiality

Hertfordshire Mind Network adheres to the Data Protection Act 2018’s principles of good information handling and the EU General Data Protection Regulation 2018.
 

Please indicate below if you consent to us collecting, recording and processing your personal data for the purpose of providing you with support and to ensure your health, safety and wellbeing. We will use your information appropriately and in line with our Privacy Policy which you can see here: Privacy Policy
 

Your details will not be shared with anyone else without your consent. If you have any concerns or questions about how your personal data is collected and used, please ring us on 02037 273600 or email us at info@hertfordshiremind.org. Please note that without your consent, you will not be able to submit this form and access Hertfordshire Mind Network’s services.
 

Where information is given in confidence that Hertfordshire Mind Network believes poses a risk to the client, a risk to other people, a risk to the safety and welfare of a child, or is against the law, we reserve the right to disclose that information to a relevant third party.

Do you consent to us collecting, recording and processing your personal data for the purpose of providing you with support and to ensure your health, safety and wellbeing? *
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Hertfordshire Mind Network Newsletter

Please register if you would like to receive our quarterly Newsletter by email.

Your details

Name *

Marketing permissions

Please confirm that you are happy for us to contact you by email to send the newsletter

Checkboxes *

Your privacy is important to us, we keep your information safe and we will never sell or swap your details for marketing purposes. You can easily unsubscribe at any time by emailing us at marketing@hertfordshiremind.org You can see our Privacy Policy here: Privacy Policy
 

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  • Home
  • Who we are
    • About us
    • Our vision, purpose and values
    • Our impact
    • Our Leadership Team
    • Our Trustees
  • Services for Adults
    • Search for Services for Adults

      Filter all our services to find the services that might be right for you.

    • the photo shows a desk inside containing a laptop computerMental Health Information

      When you’re living with a mental health problem, or supporting someone who is, having access to the right information about a condition, treatment options, or practical issues, is vital.

    • Crisis Support
      • Nightlight Crisis Helpline
      • Nightlight Crisis Cafés
      • Nightlight Crisis House
      • A and E Crisis Liaison Service
    • Peer Support Service
      • 1:1 Peer Support
      • Peer Learning Courses
      • Peer Mentoring
      • Peer Support Academy
      • Peer Support Groups
      • Carers Support
    • Community Support
      • Community Support Service
      • Complex Needs Housing Service
      • Domestic Abuse Service
      • Flourish – Refugee and Asylum Seeker Service
      • Housing Support Service
      • Primary Care Network Service
      • Bounce Back
    • Counselling
      • NHS Talking Therapies – Counselling
      • Talk It Out Counselling
      • Counselling Placements
    • Groups and Activities
      • Online Carers Group
      • Meeting Places
      • Mums Matter
      • Music Groups
      • LGBTQ+ Group
  • Services for Young People
  • Training
  • Support us
    • the photo shows four piles of coins on top of soil, with green plants emerging from the top of the coinsDonate to us

      Your donation will make a real difference to the lives of people experiencing mental ill health in Hertfordshire.

    • Indian Sizzler Night

      Join us for our second Indian Sizzler evening – a night of delicious food, community connection, and support for mental health!

    • The Great Big Walk for Herts

      We’re proud to be taking part in the Great Big Walk for Herts once again – a special event bringing together 12 local charities to walk the full 180-mile Hertfordshire Way in a single day.

    • Fundraise for your local Mind
      • Corporate Fundraising
      • Fundraise for us
      • Fundraising ideas and resources
      • Legacy Giving
      • Mindful Partners
      • Thank you to all those who donated
      • The Great Big Walk for Herts
  • Join us
    • Work for us
      • CYP Sessional Counsellor
      • Domestic Abuse Caseworker
      • Flourish Team Leader
      • HR, Training and Marketing Placement (unpaid)
      • Sessional CFD Counsellor
      • Student Placement (unpaid)
    • Volunteer with us
      • Carers Peer Support Volunteer
      • Community Support Service Volunteer
      • Counselling Placements
      • CYP ‘Future Youth’ Mentor
      • Gardener Volunteer
      • Group Volunteer
    • Community Engagement
    • Client Engagement and Involvement
      • Interview Panellist
      • Training Course Advisor
      • Events Volunteer
  • Latest
  • Contact us
Please enable JavaScript in your browser to complete this form.

Hertfordshire Mind Network Referral Form

Please complete this form if you would like to access our services and we will contact you to discuss next steps. Please give as much information as possible.

Your Details

Name *
Please tick all the ways that we can use to contact you? ? *
Is it OK for us to leave a message on your mobile?
Do you need an interpreter?

Emergency contact details

In the event of an emergency, who would you like us to contact?

GP Surgery

Employment information

Employment information *

Housing status

Are you homeless, in temporary accommodation, or facing eviction? *
Housing status *

Hospital admission

Have you been discharged from Watford A and E, Lister A&E, Kingfisher Court or Albany Lodge within the last 7 days? *

Further information

Which 1:1 service would you like to access? (If you are unsure of which service you would like to access, please call 0203 727 3600 Mon to Fri 9am - 5pm to discuss) *
If you would like to attend groups and activities, which one(s) interest you? *
How did you hear about us?

Details of referrer

(if completing the form on behalf of someone else)

Equal Opportunities and Disability Monitoring

Age Group *
Gender *
Religion/ faith *
Sexual orientation *
Disability: Are your day-to-day activities limited because of a health problem or disability which has lasted or expecting to last for at least 12 months? *
Ethnicity *
Caring responsibilities
Relationship status
Autism

Data Protection and Confidentiality

Hertfordshire Mind Network adheres to the Data Protection Act 2018’s principles of good information handling and the EU General Data Protection Regulation 2018.
 

Please indicate below if you consent to us collecting, recording and processing your personal data for the purpose of providing you with support and to ensure your health, safety and wellbeing. We will use your information appropriately and in line with our Privacy Policy which you can see here: Privacy Policy
 

Your details will not be shared with anyone else without your consent. If you have any concerns or questions about how your personal data is collected and used, please ring us on 02037 273600 or email us at info@hertfordshiremind.org. Please note that without your consent, you will not be able to submit this form and access Hertfordshire Mind Network’s services.
 

Where information is given in confidence that Hertfordshire Mind Network believes poses a risk to the client, a risk to other people, a risk to the safety and welfare of a child, or is against the law, we reserve the right to disclose that information to a relevant third party.

Do you consent to us collecting, recording and processing your personal data for the purpose of providing you with support and to ensure your health, safety and wellbeing? *
Loading
Get help now Donate
Please enable JavaScript in your browser to complete this form.

Hertfordshire Mind Network Newsletter

Please register if you would like to receive our quarterly Newsletter by email.

Your details

Name *

Marketing permissions

Please confirm that you are happy for us to contact you by email to send the newsletter

Checkboxes *

Your privacy is important to us, we keep your information safe and we will never sell or swap your details for marketing purposes. You can easily unsubscribe at any time by emailing us at marketing@hertfordshiremind.org You can see our Privacy Policy here: Privacy Policy
 

Loading

Search our site

  • Home
  • Who we are
    • About us
    • Our vision, purpose and values
    • Our impact
    • Our Leadership Team
    • Our Trustees
  • Services for Adults
    • Search for Services for Adults

      Filter all our services to find the services that might be right for you.

    • the photo shows a desk inside containing a laptop computerMental Health Information

      When you’re living with a mental health problem, or supporting someone who is, having access to the right information about a condition, treatment options, or practical issues, is vital.

    • Crisis Support
      • Nightlight Crisis Helpline
      • Nightlight Crisis Cafés
      • Nightlight Crisis House
      • A and E Crisis Liaison Service
    • Peer Support Service
      • 1:1 Peer Support
      • Peer Learning Courses
      • Peer Mentoring
      • Peer Support Academy
      • Peer Support Groups
      • Carers Support
    • Community Support
      • Community Support Service
      • Complex Needs Housing Service
      • Domestic Abuse Service
      • Flourish – Refugee and Asylum Seeker Service
      • Housing Support Service
      • Primary Care Network Service
      • Bounce Back
    • Counselling
      • NHS Talking Therapies – Counselling
      • Talk It Out Counselling
      • Counselling Placements
    • Groups and Activities
      • Online Carers Group
      • Meeting Places
      • Mums Matter
      • Music Groups
      • LGBTQ+ Group
  • Services for Young People
  • Training
  • Support us
    • the photo shows four piles of coins on top of soil, with green plants emerging from the top of the coinsDonate to us

      Your donation will make a real difference to the lives of people experiencing mental ill health in Hertfordshire.

    • Indian Sizzler Night

      Join us for our second Indian Sizzler evening – a night of delicious food, community connection, and support for mental health!

    • The Great Big Walk for Herts

      We’re proud to be taking part in the Great Big Walk for Herts once again – a special event bringing together 12 local charities to walk the full 180-mile Hertfordshire Way in a single day.

    • Fundraise for your local Mind
      • Corporate Fundraising
      • Fundraise for us
      • Fundraising ideas and resources
      • Legacy Giving
      • Mindful Partners
      • Thank you to all those who donated
      • The Great Big Walk for Herts
  • Join us
    • Work for us
      • CYP Sessional Counsellor
      • Domestic Abuse Caseworker
      • Flourish Team Leader
      • HR, Training and Marketing Placement (unpaid)
      • Sessional CFD Counsellor
      • Student Placement (unpaid)
    • Volunteer with us
      • Carers Peer Support Volunteer
      • Community Support Service Volunteer
      • Counselling Placements
      • CYP ‘Future Youth’ Mentor
      • Gardener Volunteer
      • Group Volunteer
    • Community Engagement
    • Client Engagement and Involvement
      • Interview Panellist
      • Training Course Advisor
      • Events Volunteer
  • Latest
  • Contact us

Herts Mind Network

The Wellbeing Centre
501 St Albans Road
Watford
Hertfordshire WD24 7RZ

020 3727 3600
info@hertfordshiremind.org

Charity Number: 1112487
Registration Number: 5532977

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Herts Mind Network

The Wellbeing Centre
501 St Albans Road
Watford
Hertfordshire WD24 7RZ

020 3727 3600
info@hertfordshiremind.org

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  • Privacy Policy
  • Young Person’s Privacy Policy
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  • Accessibility Statement
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  • Complaints Procedure
  • Safeguarding Statement

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Charity No. 1112487

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