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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 *

First

Last

Main Phone *

Mobile

Email

Date of Birth *

Number/ Street *

Town *

Postcode *

Please tick all the ways that we can use to contact you? *

Home phone
Mobile
Email

Is it OK for us to leave a message on your mobile?

Yes
No

What is your first language? *

Do you need an interpreter?

Yes
No

Emergency contact details

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

Name

Contact number

Relationship to you

GP Surgery

GP Surgery *

Employment information

Employment information *

Employed
Unemployed
Not working due to illness
Retired
Veteran
Carer
Student

Housing status

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

Yes
No

Housing status *

Private rented
Private owned
Living with family or friends
Supported living
Housing Association
Hotel
Not applicable

Please name your housing association (if applicable)

Hospital admission

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

Yes
No

If yes, please state which hospital you were in

One to One Services

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) *

1:1 Peer Support
Bounce Back
Carers Support
Community Support Service
Employment Support
Flourish
Housing Support
Mums Matter Peer Support (for Mums with perinatal mental health needs and children under 2 years old)
Peer Mentoring Service
Primary Care Network Service
Social Support Service
I am not looking for 1:1 support

If you are referring to the Flourish service: Please confirm the immigration status, county of origin and how long you, or the person you are referring, has lived in the UK.

If you would like to access counselling, please visit our counselling section and find out how to refer to these services

Groups

If you would like to attend groups and activities, which one(s) interest you? *

Decluttering Peer Support Group
Flourish Group
Meeting Places (Online and Face to Face)
Mums Matter (for Mums with perinatal mental health needs and children under 2 years old)
Music Group
Online Carers Support Group
Online LGBTQ Group
Peer Support Group
I do not want to attend groups

Further information

What are your three main concerns that are affecting your wellbeing at the moment? *

How did you hear about us?

GP
Wellbeing Service/ IAPT
Mental Health Team
Adult Care Services
CAMHS
Promotional event
Probation
Previously used HMN
Friend or family
Our website
Social media
Frontline
Other

Other - How did you hear about us?

Details of referrer

(if completing the form on behalf of someone else)

Are you a professional completing this form on behalf of someone?

Yes
No

For professionals only. Please add any information we should be aware of:

Name of referrer

Email

Organisation

Tel number

Equal Opportunities and Disability Monitoring

Age Group *

17 or under
18-24
25-34
35-44
45-54
55-64
65-74
75-84
85-89
90+
Prefer not to say

Gender *

Male
Female
Transgender
Non-binary
Prefer not to say

Other gender description (please specify)

Religion/ faith *

No religion/ faith
Christian (any denomination)
Buddhist
Hindu
Humanist
Sikh
Muslim
Jewish
Other
Prefer not to say

Other - please specify

Sexual orientation *

Bisexual
Gay or Lesbian
Heterosexual
Prefer not to say
Other sexual orientation description

Please specify other sexual orientation description

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? *

None
Physical disability
Sensory impairment (such as sight or hearing)
Long-term illness or condition
Learning disability
Mental health condition
ASD/ ADHD
Prefer not to say
Other disability description (please specify)

Please specify other disability description

Ethnicity *

White British
White Irish
Gypsy or Irish Traveller
Roma
Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Any other mixed background
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian Background
Caribbean
African
Any other Black background
Any other ethnic group
Prefer not to say

Relationship status

Single
Married
Civil Partnership
Divorced
Widowed
Cohabiting
Prefer not to say

Caring responsibilities

Primary carer of a child (under 18)
Primary carer of older person
Primary carer of disabled child/ children (under 18)
Primary carer of disabled adult (18 and over)
None

Autism

Autism diagnosis
Awaiting autism assessment
Not applicable

ADHD

ADHD diagnosis
Awaiting ADHD assessment
Not applicable

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? *

Yes
No (Please note, we need consent to process your referral)

Get help now Donate

Search our site

Home
Who we are
For Adults
For Young People
Training
Support us
Join us
Get Involved
- Client Engagement and Involvement
- Community Engagement
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 *

First

Last

Main Phone *

Mobile

Email

Date of Birth *

Number/ Street *

Town *

Postcode *

Please tick all the ways that we can use to contact you? *

Home phone
Mobile
Email

Is it OK for us to leave a message on your mobile?

Yes
No

What is your first language? *

Do you need an interpreter?

Yes
No

Emergency contact details

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

Name

Contact number

Relationship to you

GP Surgery

GP Surgery *

Employment information

Employment information *

Employed
Unemployed
Not working due to illness
Retired
Veteran
Carer
Student

Housing status

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

Yes
No

Housing status *

Private rented
Private owned
Living with family or friends
Supported living
Housing Association
Hotel
Not applicable

Please name your housing association (if applicable)

Hospital admission

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

Yes
No

If yes, please state which hospital you were in

One to One Services

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) *

1:1 Peer Support
Bounce Back
Carers Support
Community Support Service
Employment Support
Flourish
Housing Support
Mums Matter Peer Support (for Mums with perinatal mental health needs and children under 2 years old)
Peer Mentoring Service
Primary Care Network Service
Social Support Service
I am not looking for 1:1 support

If you are referring to the Flourish service: Please confirm the immigration status, county of origin and how long you, or the person you are referring, has lived in the UK.

If you would like to access counselling, please visit our counselling section and find out how to refer to these services

Groups

If you would like to attend groups and activities, which one(s) interest you? *

Decluttering Peer Support Group
Flourish Group
Meeting Places (Online and Face to Face)
Mums Matter (for Mums with perinatal mental health needs and children under 2 years old)
Music Group
Online Carers Support Group
Online LGBTQ Group
Peer Support Group
I do not want to attend groups

Further information

What are your three main concerns that are affecting your wellbeing at the moment? *

How did you hear about us?

GP
Wellbeing Service/ IAPT
Mental Health Team
Adult Care Services
CAMHS
Promotional event
Probation
Previously used HMN
Friend or family
Our website
Social media
Frontline
Other

Other - How did you hear about us?

Details of referrer

(if completing the form on behalf of someone else)

Are you a professional completing this form on behalf of someone?

Yes
No

For professionals only. Please add any information we should be aware of:

Name of referrer

Email

Organisation

Tel number

Equal Opportunities and Disability Monitoring

Age Group *

17 or under
18-24
25-34
35-44
45-54
55-64
65-74
75-84
85-89
90+
Prefer not to say

Gender *

Male
Female
Transgender
Non-binary
Prefer not to say

Other gender description (please specify)

Religion/ faith *

No religion/ faith
Christian (any denomination)
Buddhist
Hindu
Humanist
Sikh
Muslim
Jewish
Other
Prefer not to say

Other - please specify

Sexual orientation *

Bisexual
Gay or Lesbian
Heterosexual
Prefer not to say
Other sexual orientation description

Please specify other sexual orientation description

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? *

None
Physical disability
Sensory impairment (such as sight or hearing)
Long-term illness or condition
Learning disability
Mental health condition
ASD/ ADHD
Prefer not to say
Other disability description (please specify)

Please specify other disability description

Ethnicity *

White British
White Irish
Gypsy or Irish Traveller
Roma
Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Any other mixed background
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian Background
Caribbean
African
Any other Black background
Any other ethnic group
Prefer not to say

Relationship status

Single
Married
Civil Partnership
Divorced
Widowed
Cohabiting
Prefer not to say

Caring responsibilities

Primary carer of a child (under 18)
Primary carer of older person
Primary carer of disabled child/ children (under 18)
Primary carer of disabled adult (18 and over)
None

Autism

Autism diagnosis
Awaiting autism assessment
Not applicable

ADHD

ADHD diagnosis
Awaiting ADHD assessment
Not applicable

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? *

Yes
No (Please note, we need consent to process your referral)

Get help now Donate

Search our site

Home
Who we are
For Adults
For Young People
Training
Support us
Join us
Get Involved
- Client Engagement and Involvement
- Community Engagement
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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Contact Us

Herts Mind Network

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

020 3727 3600
info@hertfordshiremind.org

Terms

Privacy Policy
Young Person’s Privacy Policy
Cookie Policy
Accessibility Statement
Terms and Conditions
Complaints Procedure
Safeguarding Statement

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© 2026 Herts Mind Network
Registered in England and Wales 5532977
Charity No. 1112487

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Fundraise

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Your Fundraising Campaign

Please enter as much information as possible. Once submitted it will be reviewed by a member of our fundraising team and we will email you a link to your fundraising page within 72 hours.

Your Name *

First

Last

Your Email Address: *

This will be used to notify you when your donation form goes live - we will send you a link to your fundraising page.

Your Campaign Name: *

This will be the name of your page - if you are taking part as a group this can be a team name or your own personal page if you prefer. If you choose to register as a team - there will be only one point of contact.

Set your target goal you are aiming to raise: *

The amount of funds you want to raise

Campaign Category *

If you’d like to fundraise for one of our campaigns, please select it from the list.
Choose Fundraise Your Way to start a general fundraising campaign for Herts Mind Network.

Your Profile Image: *

Drag & Drop Files, Choose Files to Upload

Please upload an image for your campaign. Must be minimum 600x600 pixels. File formats: jpg, jpeg, png

Your Reason for Raising Funds for us. *

Example:
Paragraph 1: Who you are
Paragraph 2: Why you are passionate about Herts Mind Network
Paragraph 3: Why others should also support us.