Member type	Public Staff Patient & Carer
Title	Unspecified Mr Mrs Miss Ms Mx Dr Professor Wing Commander Capt Canon Reverend Col Major Commodore Cllr Sister Master Lady Mayor Pastor 2nd Lieutenant Princess Prince Priestess Rev Dr
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

Special Postal Requirements	Large Print Audio tapes Braille Other (please list in ‘Notes’ section)
Disabilities	No Yes A mental health problem A sensory disability A physical disability A learning disability Any other special need (please list in the 'Notes' section)
How would you like to be involved?	Receive Newsletters Do you volunteer with SLaM Attend Events Voting in the Election Be Part of the Members Council or stand for Election
Service preferences?	Addictions Child and Adolescent Mental Health Adult Mental Health Older Adult Mental Health (65+)

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
Special Postal Requirements
Preferred method of contact
Disabilities
How would you like to be involved?
Service preferences?

*  I apply to be a member of South London and Maudsley 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.