Self Referral | Clear Mind

Name *

Date of Birth *

Contact Number *

Email address *

Address *

What Support are you looking for *

Befriending Support ( Over the Phone)
Food & Toiletries Support
I'm not sure

Tell us a little bit about what has been going on

Do you have any accessibility / communication needs? ( please type no if you do not) *

Other Support - are you receiving support from anyone else ? ( if yes, please tell us who this is) *

Safety & Wellbeing - Is there anything that might affect your safety or wellbeing that you’d like us to be aware of?

Consent *

I agree to Clear Mind Derby contacting me about this referral
I consent to Clear Mind Derby storing my information securely
I understand Clear Mind Derby may share information with partner agencies only where necessary to support me

What this form will ask you for

Your details

So we know how to contact you

What kind of support you’re looking for

This helps us direct your referral to the right part of our team.

A short description of what’s going on

Just a few lines is enough — whatever feels comfortable for you.

Any accessibility or communication needs

So we can make sure our support works for you.

Whether you’re getting support from anyone else

This helps us avoid duplication and understand who else is involved.

Consent

We’ll ask you to confirm that you’re happy for us to contact you and store your information securely.

What happens next

Once you submit the form:

A member of our team will read your referral
We’ll contact you directly
We may ask a few extra questions, but only if needed
We’ll talk with you about the best next steps

Clear Mind Derby is a warm, safe and supportive space. You’re welcome here.