Member type	Public Staff Patient & Carer
Title	Unspecified Mr Mrs Miss Ms Dr Professor Canon Reverend Capt Wing Commander Col Major Commodore Cllr Sister Master Lady Mayor Pastor 2nd Lieutenant Princess Prince Priestess Rev Dr
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Date of birth *	DD MM YYYY
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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 sensory disability A physical disability A learning disability A mental health problem Any other special need (please list in the 'Notes' section)
How would you like to be involved?	Receive Newsletters Voting in the Election Attend Events Be Part of the Members Council or stand for Election Do you volunteer with SLaM
Service preferences?	Addictions Child and Adolescent Mental Health Adult Mental Health Older Adult Mental Health (65+)

Member type
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?

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