Please fill in your details below to become a member of Central and North West London NHS Foundation Trust
Fields marked with * are mandatory.
1. Personal Information
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
Please enter your postcode, and click Get Address
Address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
Please provide your email address to help us communicate with you faster and reduce our environmental impact.
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
2. Additional Information
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
3. Review
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:
4. Finish
*
I apply to be a member of Central and North West London NHS Foundation Trust and be bound by the rules of the organisation. I give consent to the processing of my information.
The data you supply will be used only to contact you about the Trust, membership or other related issues and will be stored in accordance with the current Data Protection Act. Please click
here
for full details.
Please tick here if you consent to your details being added to the Public Register.