Self-Refer to the Service

Use the form below to refer yourself to our service.

    How can we contact you? Please select all that apply (AT LEAST ONE):

    EMERGENCY CONTACT
    Please let us have details of an emergency contact if you have one:

    MEDICAL / WELFARE

    Do you know the name of your GP Surgery / Practice?

    Your Gender (please click ONE box):

    YOUR INTEREST IN OUR SERVICE

    I am interested in:

    CONFIDENTIALITY

    Futures in Mind groups are designed for those in active recovery from alcohol or substance misuse or with mental health issues. You must be assessed before you can join the service or participate in a group activity. Once you submit this form, one of our team will get in touch within 14 days.

    Futures in Mind are committed to maintaining confidentiality. All information about you is kept securely and not shared with anyone outside our organisation without your permission, or unless exceptional circumstances occur. Your data is held electronically on a secure data base.

    If we believe there is a risk of harm to you or others we will inform the appropriate persons (such as relevant agencies and services), but we would always endeavour to let you know about this in advance.

    Please sign by entering your name and date below to indicate you have read and understood this statement.

    You can also download the form as a Word file to complete offline and send by post: