Please fill in your details below to become a member of South London and Maudsley NHS Foundation Trust
Fields marked with * are mandatory.
1. Personal Information
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
Sir
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
2. Additional Information
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+)
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
Ethnicity
Special Postal Requirements
Preferred method of contact
Disabilities
How would you like to be involved?
Service preferences?
4. Finish
*
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.