Bereaved By Suicide Registration Form
Your Details:
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Gender Identity
*
Please Select
Male
Female
Non-Binary
Other
Address
*
Street Address
Street Address Line 2
City
County
Post Code
E-mail
*
example@example.com
Phone Number
*
A mobile number is preferred
Contact Preferences
*
Email
Telephone
Can we leave a voicemail?
*
Yes
No
Reason for referral
*
Please tell us briefly why you are self-referring to this service.
GP Details
Please provide details of your GP.
GP Name
*
Phone Number
Address
*
Street Address
Street Address Line 2
City
County
Post Code
Next of Kin
Please provide details of a next of kin in the event of a medical emergency.
Name
*
First Name
Last Name
Phone Number
*
Relationship to you
*
GDPR Statement
Any personal information will only be used to process your requests, to provide you with our services, and to provide you with information relating to our services and any other services which we think you may be interested in. We will usually only share your information with other agencies if it is relevant to your enquiry and we have obtained your consent. You can choose to withdraw consent at any time.There are some circumstances in which we will share your information, even if you have not given us your permission to do so. These are:- When there is a serious risk to you or to other people.- When there is a legal requirement to share information, such as a serious crime, or a child protection issue.
*
I have read and understood the above GDPR statement and agree to be contacted by Herefordshire Mind
Please verify that you are human
*
Submit
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