Title	Unspecified Mr Mrs Miss Ms Dr Professor Canon Reverend Wing Commander Lieutenant colonel Capt Col Major Commodore Cllr Sister Master Lady Mayor
First name *
Last name *
Middle name
Date of birth *	DD MM YYYY
Gender	Unspecified Male Female Transgender
	Please enter your postcode, and click Get Address
Address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
Email
Twitter
Ethnic Origin	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

Disabilities	No Yes A sensory disability (please specify) A physical disability (please specify) A learning disability (please specify) A mental health problem (please specify) Any other special need (please specify)
How would you like to be involved?	Armchair consultation – receive emails to give your views on leaflets, policies and other Trust docs Attending focus groups for planning or developing services Improving and/or delivering staff training programmes Attending service user and carer forums to feedback on services Taking part in intensive “Rapid Process Improvement Workshops” to improve quality of services Taking part in the recruitment of new staff Enrol in Wellbeing+Recovery College using your experience of services to develop & deliver training Helping with surveys, audits and/or research projects Hospital / environment inspections Taking part in panels for judging awards for staff and/or service users and carers Involvement representative – enthusiasm for the role, to be a buddy/champion to support our new recr Graphic design work for Trust publications / initiatives / events Writing articles / leaflets / other literature for the Trust Presenting and/or co-chairing at Trust meetings or events Interested in volunteer opportunities with the Trust
Service preferences?	Children's Services Medicines Management and Pharmacy Drug and Alcohol Prison in reach Learning Disabilities Mother and Baby Services Non-Clinical Services Forensic Mental Health Older Adults Mental Health Eating Disorders Substance Misuse Adults of Working Age Mental Health Occupation Therapy Dignity and Respect Early Recognition of People in Need General Interests Other Involve - Shropshire – Physical Health Services Involve - Shropshire – Mental Health Services Involve - Shropshire – Social Care Involve - Shropshire – Other Involve - South Staffs – Physical Health Services Involve - South Staffs – Mental Health Services Involve - South Staffs – Social Care Involve - South Staffs - Other Involve - North Staffs – Physical Health Services Involve - North Staffs – Mental Health Services Involve - North Staffs – Social Care Involve - North Staffs - Other Involve - Out of area – Physical Health Services Involve - Out of area – Mental Health Services Involve - Out of area – Social Care Involve - Out of Area – Other
How are you connected with the Trust?	Service User Carer Member of the Public Volunteer SSOTP Member
How did you hear about the trust?	Event Through an Employee Website Online Membership Form PALS Other (please specify)

Last Used Services
Title
First name
Last name
Middle name
Date of birth
Gender
Address
County
Postcode
Country	UK
Home telephone
Mobile
Email
Twitter
Ethnic Origin
Disabilities
How would you like to be involved?
Service preferences?
How are you connected with the Trust?
How did you hear about the trust?

*  I apply to be a member of Midlands Partnership 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.