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 Parcel
Toiletries Parcel
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?

I agree to being contacted about this referral *

Yes
No

I consent to Clear Mind Derby storing my information securely and understand Clear Mind Derby may share information with partner agencies only where necessary to support me and / or others *

Yes
No

Send me a copy

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 stepsPlease be advised: Due to capacity and demand there is currently a six week wait for befriending support from the time of your referral, we are working hard to reduce the wait and will update you as soon as we have availability.
We will be in touch with you within 3 working days if you require a Food / Toiletries Parcel.

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