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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 provide as much information as possible.

Your Details

Name *

First

Last

Main Phone

Mobile

Email *

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Please complete this section carefully. Supporting you to access the right services is very important to us but it isn't always easy to make contact, so listing as many contact options as possible will help us to help you more quickly.

Contact method

How would you like us to contact you?

Home phone
Mobile
Email

Is it OK for us to leave a message?

GP Surgery

Emergency Contact Information

Please confirm that you have the consent of the person for Herts Mind Network to contact in an emergency by ticking the checkbox below

My emergency contact has given their consent

Name

Contact number

Relationship to you

Employment information

Employed
Unemployed
Not working due to illness
Retired
Veteran
Carer
Student

Further information

Which services would you like to access or like more information about?

1:1 Peer Support
Peer Learning Courses
Peer Support Groups
1:1 Peer Mentoring
Housing Support Service
Community Support Service
Domestic Abuse Service
Domestic Abuse Service (Prevention)
Counselling
Three Rivers Healthy Hub
Live Well Dacorum
Mums Matter
Online Meeting Places
Online LGBTQ Group
Hertswise
BBO Strive in Hertfordshire
BBO Herts Youth Futures

Please provide some information about your current situation and what support you are looking for? *

Is there any additional information we need to know for you to access our services? e.g. language, disability, access issues? *

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
Other

Other - How did you hear about us?

Details of referrer

(if completing the form on behalf of someone else)

Name of referrer

Organisation

Tel number

Equal Opportunities and Disability Monitoring

Age Group *

18 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
The gender above is not the one given to me at birth
Prefer not to say

Other gender description (please specify)

Religion/ faith

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

Other - please specifiy

Sexual orientation

Bisexual
Gay man
Lesbian/ Gay woman
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 impairment (such as mobility)
Behavioural/emotional
Sensory impairment (such as sight or hearing)
Long-term illness or condition
Learning disability
Mental health condition
Prefer not to say
Other disability description (please specify)

Please specify other disability description

Ethnicity

White English / Welsh / Scottish / Northern Irish / British
White Irish
White Gypsy or Irish Traveller
Any other white background (please specify below)
Mixed White and Black Caribbean
Mixed White and Black African
Mixed White and Asian
Any other mixed background (specify below)
Black or British African
Black or British Caribbean
Any other black background (specify below)
Asian or British Indian
Other ethnicity description (please specify)
Asian or British Pakistani
Asian or British Bangladeshi
Asian or British Chinese
Any other Asian Background (specify below)
Prefer not to say

Please specify other ethnicity

Caring responsibilities

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

Relationship status

Single
Married
Civil Partnership
Divorced
Widowed
Prefer not to say

Autism

Autism diagnosis
Awaiting autism assessment

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.

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? *

Providing mental health support across Hertfordshire

for Children and Young People

Welcome to Herts Mind Network CYP

Welcome to our Children and Young People’s website.

As well as providing services for adults, at Hertfordshire Mind Network we also have dedicated services for children and young people across the county. This site provides information about our CYP services, resources for families, carers and professionals and details of our upcoming training courses.

As a local mental health charity in Hertfordshire we are here for children and young people across the county that need support with their mental health and wellbeing.

How can we help you today?

I would like...

to get some help now. to see how you can support my school. to speak to someone. some one-to-one mentoring. to see what online services you offer information on the training you provide to do some fundraising.

2,426

Children and young people were supported in the last year

794

Parents attended Children & Young People workshops in the last year.

856

One-to-one support sessions were provided by Herts Youth Futures in the last year.