Member type	Public Staff Patient/Carer
Title	Unspecified Mr Mrs Miss Ms Dr Professor Canon Reverend Wing Commander Capt Col Major Commodore Cllr Sister Master Lady Mayor Honour Judge Madam Sir Father Dame
First name *
Last name *
Middle name
Date of birth *	DD MM YYYY
Gender	Unspecified Male Female
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Address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
Email
Preferred method of contact	Email Post Telephone SMS
Ethnicity	Not stated White - English, Welsh, Scottish, Northern Irish, British White - Irish White - Gypsy or Irish Traveller White - Other Mixed - White and Black Caribbean Mixed - White and Black African Mixed - White and Asian Mixed - Other Mixed Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Asian or Asian British - Chinese Asian or Asian British - Other Asian Black or Black British - African Black or Black British - Caribbean Black or Black British - Other Black Other Ethnic Group - Arab Other Ethnic Group - Any Other Ethnic Group
Faith	Not Stated None / Atheist Agnostic Church of England Other Protestant Orthodox Christian Roman Catholic Other Christian Sikh Jewish Buddhist Hindu Muslim Jain Parsi / Zoroastrian Rastafarian Other Faith group Do not wish to disclose
Sexual Orientation	Not Stated Heterosexual Gay Lesbian Bisexual Do not wish to disclose
Any accessibility or special requirements	Not Applicable Mobility Impairment Hearing Impairment Visual Impairment Cognitive Impairment Other

Borough or area you or someone you care for uses services:	Not Applicable Bedfordshire Brent Camden Ealing Harrow Hillingdon Kensington & Chelsea Milton Keynes Surrey Westminster Other
Types of involvement activity you have interest in (please tick as many as apply):	Not Applicable Helping interview and select new staff members Helping to write policies and documents Getting involved in a Quality Improvement project Taking part in a research project Joining a group of other patients and carers to meet regularly to influence services Helping to plan conferences and events Producing or delivering training to staff Taking part in consultation workshops on specialist topics - e.g. medication, Care Programme Telling your story at a board meeting Getting involved in local activities for patients and carers Other
Type of service you have recent experience of (within the last 3 years) - please tick as many as apply:	Not Applicable Addictions and substance misuse services Eating disorder services Learning disability services Adult Inpatient Mental Health Services Adult Community Mental Health Services Older Adult Mental Health Services Child and Adolescent Mental Health Services Mental Health Rehabilitation Services Adult Physical Health Services Older Adult Physical Health Services Community Independence Services Childrens Physical Health Services Palliative Care Services Sexual Health Services Offender Care Services Other
How did you hear about the Trust?	CNWL website Social media (e.g. Twitter, Facebook or YouTube) Face to face recruitment Through an employee of the trust Paitient mailing Other
If you have had any previous training or relevant experience, please tick:	Tick to add text

Member type
Last Used Services
Title
First name
Last name
Middle name
Date of birth
Gender
Address
County
Postcode
Country	UK
Home telephone
Mobile
Email
Ethnicity
Faith
Sexual Orientation
Any accessibility or special requirements
Borough or area you or someone you care for uses services:
Preferred method of contact
Do you consider yourself to be disabled?
Types of involvement activity you have interest in (please tick as many as apply):
Type of service you have recent experience of (within the last 3 years) - please tick as many as apply:
How did you hear about the Trust?
If you have had any previous training or relevant experience, please tick:

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