Please fill in your details below to become a member of Leicestershire Partnership NHS Trust
Fields marked with * are mandatory.
1. Personal Information
Title
Unspecified
Mr
Mrs
Miss
Ms
Dr
Professor
Canon
Reverend
Wing Commander
Capt
Col
Major
Commodore
Cllr
Sister
Master
Lady
Mayor
Sergeant
Lord
Sir
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
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
Christian
Muslim
Hindu
Jewish
Buddhist
Sikh
Humanist
Pagan
None
Prefer not to say
Other
Sexual Orientation
Not Stated
Lesbian
Gay
Heterosexual
Bisexual
Prefer not to state
2. Additional Information
Special Postal Requirements
Large Print
Audio tapes
Braille
Other (please list in ‘Notes’ section)
Disabilities
No
Yes
A sensory disability
A physical disability
A learning disability
A mental health problem
Any other special need (please list in the 'Notes' section)
How would you like to be involved?
Complete questionnaire
Receive Regular Information
Attend Meetings and Events
Become a Volunteer
Become a Hear My Voice volunteer
Service preferences?
Occupational Therapy
Physiotherapy
Speech & Language Therapy
Podiatry/Chiropody
Specialist Continence Nursing
End of Life Nursing Care
District Nursing
Specialist Nurses: Long Term Conditions
Community Hospital
Mental Health Services for Older People
Adult Mental Health Services
Learning Disability Services
Audiology
Health Visiting
Health Promotion & Prevention (Children)
Travelling Families Services
School Nursing
Nutrition & Dietetics
Paediatric Medicine
Psychosis Intervention & Early Recovery (PIER)
Drug & Alcohol
Eating Disorders
Child & Adolescent Mental Health
Stop Smoking Services
Chlamydia & Sexual Health Promotion
Food & Activity Buddies
Genito Urinary Medicine (Loughborough)
Medicine
Women's health
Children's services
Surgery
National Spinal Injuries Centre
Outpatient services
Other support services (please list in ‘Notes’ section)
Forensic Mental Health Services
Working Groups on Specific Topics
How did you hear about the Trust?
Online Application
Public meetings
Public consultation mailing
Other (please list in 'Notes')
Trust Website
Radio Advertising
3. Review
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
Special Postal Requirements
Preferred method of contact
Disabilities
How would you like to be involved?
Service preferences?
How did you hear about the Trust?
4. Finish
*
I apply to be a member of Leicestershire Partnership NHS 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
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for full details.
Please tick here if you consent to your name and constituency being added to the Public Register.