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
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Middle name
Date of birth *	DD MM YYYY
Gender	Unspecified Male Female Transgender
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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

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)

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?

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