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

Emergency contact details

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

GP Surgery

Employment information

Housing status

Hospital admission

Further information

Details of referrer

(if completing the form on behalf of someone else)

Equal Opportunities and Disability Monitoring

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 [email protected]. 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.