Fields marked with * are mandatory.
1. Personal Information
Member type
Public
Carer
Patient/Service User
Title
Unspecified
Mr
Mrs
Miss
Ms
Dr
Professor
Canon
Reverend
Wing Commander
Capt
Col
Major
Commodore
Cllr
Sister
Master
Lady
Mayor
Sir
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
Home address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
Email
Twitter
Preferred method of contact
Email
Post
Telephone
SMS
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
Religion/Belief
Agnostic
Atheist
Christian
Hindu
Jehovah's Witness
Jewish
Methodist
Muslim
Not Stated
Other
Sikh
2. Additional Information
Special Postal Req
Other (please list in ‘Notes’ section)
Easy Read
Large Print
Audio Tapes
Braille
On Electoral Roll?
Yes
No
Not Stated
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)
Long standing illness
Not stated
How would you like to be involved?
Consider standing for election as governor
Involved in surveys, questionnaires and consultation events
Attend meetings and special events
Only receive members newsletter
Volunteer at the Trust
Service preferences?
Other support services (please specify)
Mental Health – Adult Community
Mental Health – Adult Inpatient
Mental Health – CAMHS
Mental Health – Older People Community
Mental Health – Older People Inpatient
Community – Adult
Community – Children, Young People and Families
Community Services – Inpatient
Drug and Alcohol
Not stated
Community Services
Learning Disability
Mental Health
Specialist Services
How are you connected with the Trust?
A patient
A carer
Volunteer
Have previously worked for the Trust
Interested in local health services provided by the Trust
How did you hear about the Trust?
Other (please list in 'Notes')
Friend/Family
Governor
Staff
Information Stand
Mailing
Event/Meeting
Poster
Website
Social Media (Facebook/Twitter)
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
Twitter
Ethnic Origin
Religion/Belief
On Electoral Roll?
Special Postal Req
Preferred method of contact
Disabilities
How would you like to be involved?
Service preferences?
How are you connected with the Trust?
How did you hear about the Trust?
4. Finish
*
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