General registration formPlease complete the form below to register for support from Devon Mind: Personal details Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Registered GP Surgery * I can't find my GP surgery I am not currently registered with a GP surgery Abbey Surgery Adelaide Street Surgery Albany Surgery Armada Surgery Ashburton Surgery Axminster Medical Practice Bampton Surgery, Amicus Health Barnfield Hill Surgery Barton Surgery Beacon Medical Centre Beaumont Villa Surgery Bideford Medical Centre Bishopteignton Surgery Blackdown Practice Blake House Surgery Bovey Tracey & Chudleigh Practice Bow Pedical Practice Bradworthy Surgery Bramblehaies Surgery Brannam Medical Centre Brunel Medical Practice Buckfastleigh Medical Centre Buckland Surgery Budleigh Salterton Medical Centre Budshead Medical Practice Caen Medical Centre Castle Gardens Surgery Castle Place Practice Catherine House Surgery Chaddlewood Surgery Chagford Health Centre Channel View Surgery Chelston Hall Surgery Cheriton Bishop Surgery Cheriton Fitzpaine Surgery Chilcote Surgery Chillington Health Centre Christow Surgery Chudleigh Health Centre Church View Surgery Clare House Surgery, Amicus Health Clocktower Surgery Coleridge Medical Centre College Surgery Partnership Combe Coastal Practice Compass House Medical Centre (Brixham) Compass House Medical Centre (Galmpton) Corner Place Surgery Cranbrook Medical Practice Cricketfield Surgery Croft Hall Medical Practice Crownhill Surgery Dartmouth Medical Practice Dean Cross Surgery Devon Square Surgery Devonport Health Centre Efford Medical Centre Elm Surtgery Ernesettle Medical Centre Estover Health Centre Exminster Surgery Exmouth Health Centre Foxhayes Practice Fremington Medical Centre Friary House Surgery Glasshouser Medical Centre Glendevon Medical Centre Glenside Medical Centre Haldon House Surgery Hartland Surgery Heavitree Practice Hill Barton Surgery Honiton Surgery Ide Lane Surgery Imperial Surgery Ipplepen Health Centre ISCA Medical Practice Ivybridge Health Centre Kingskerswell Health Centre Kingsteignton Medical Practice Knowle House Surgery Laira Surgery Leatside Surgery Lisson Grove Medical Centre Litchdon Medical Centre Lynton Health Centre Mannamead Surgery Mayfield Medical Centre Modbury Health Centre Morchard Bishop Surgery Moretonhampstead Health Centre Mount Gould Primary Care Centre Mount Pleasant Health Centre Neetside Surgery North Road West Medical Centre Northam Surgery Norton Brook Medical Centre Oakside Surgery Okehampton Medical Centre Old Farm Surgery Pembroke House Surgery Peverell Park Surgery & University Medical Centre Pinhoe & Broadclyst Medical Practice Plympton Health Centre Queens Medical Centre Raleigh Surgery Redfern Health Centre Redlands Primary Care (Crediton) Redlands Primary Care (Thorverton) Riverside Surgery Roborough Surgery Ruby Country Medical Group Sampford Peverell Surgery Seaton & Colyton Medical Practice Sidmouth Health Centre South Brent Health Centre South Lawn Medical Practice South Molton Medical Centre Southernhay House Surgery Southover Medical Practice Southway Surgery St Leonards Practice St Levan Surgery St Neots Surgery St Thomas Medical Group Starcross Surgery Stirling Road Medical Centre Stoke Surgery Stratton Medical Centre Tavyside Health Centre Teignmouth Medical Practice Topsham Surgery Torrington Health Centre Townsend House Medical Centre Treetops Surgery Trelawny Surgery Underhill Surgery Wallingbrook Health Centre Wembury Surgery West Hoe Surgery Whipton Surgery Winkleigh Surgery Witheridge Medical Centre Wonford Green Surgery Wooda Surgery Woodbury Surgery Wotter Surgery Wycliffe Surgery Wyndham House Surgery Yealm Medical Centre Yelverton Surgery Phone Number * (###) ### #### Email Address * Support needs What would you like us to help you with? * Please provide as much relevant detail as possible so that we can best help you. How would you prefer to be contacted? * By phone By email Either is fine If we need to contact you by phone, when would be the best day(s) and time(s) to reach you? * For example, "Anytime", "Mondays or Tuesdays after 3pm", "Weekdays between 1pm and 2pm", etc. Do you have any communication needs we may need to know about? * For example, you're hard of hearing or have difficulty reading emails, etc. Yes No If you answered 'Yes' above, please state your communication needs below: Do you have a current mental health diagnosis? * For example, depression, anxiety, bipolar, etc. Yes No If you answered 'Yes' above, please state your current diagnosis/es below: Are you currently using any other mental health services? * For example, private counselling, other support groups, etc. Yes No If you answered 'Yes' above, please state which service(s) you are currently using below: Are you interested in attending any of our support groups? If so, please select from the list below: Anxiety & Depression Group Bipolar Support Group Men's Support Group OCD Support Group Women's Support Group Confirmation Where did you hear about our services? * Community mental health team Devon Mind letter/email Devon Mind social media Devon Mind website GP/other medical professional Plymouth Options TALKWORKS Word of mouth/recommendation Don't know/can't remember We require your explicit consent to process this data because it contains details about your health. We ask you to provide this information so that we can provide you with the correct support for your needs. We will process your data in accordance with our Privacy Policy, which is available at www.devonmind.com/privacy. Please check the box below to confirm your consent. * I give my explicit consent for you to process my health data Would you like to sign up to receive the latest news and updates from Devon Mind? You are free to unsubscribe at any time. Yes, sign me up to receive news and updates from Devon Mind Thank you!
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