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Please enable JavaScript in your browser to complete this form.
Name
*
Date of birth
*
Email
*
Phone
*
Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
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Equatorial Guinea
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French Guiana
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French Southern Territories
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Gambia
Georgia
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Ghana
Gibraltar
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Greenland
Grenada
Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
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India
Indonesia
Iran (Islamic Republic of)
Iraq
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Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
I consent to Mind in the Vale of Glamorgan keeping my information in the secure database in line with General Data Protection and Mind in the Vale's
GDPR Policy
Why are you referring to Mind in the Vale?
*
My GP has advised me to refer
A nurse in my GP practice has asked me to refer
I am referring myself
Which GP practice are you registered with?
*
I am receiving support from the Vale Locality Mental Health Team
What services do you require?
*
Centre of Clinical Interventions Guided Self-Help (for example, depression, anxiety, worry...)
(?)
General Wellbeing Support
(?)
Counselling (please note, there will be a small cost for our Counselling services and there may be a waiting list)
(?)
What are the issues impacting your mental health that you need help with?
*
Assertiveness
Depression
Worry
Procrastination
Distress intolerance (regulating emotions)
Self-compassion
Self-esteem
Panic
Perfectionism
Social anxiety
What are the issues impacting your mental health that you need help with?
*
Physical health
Social (eg. housing, debt, benefits)
Mental health support
Education or employment
Addictions
Pain management
General wellbeing
You selected "General wellbeing" - please give us more information below.
I confirm I am over the age of 18
Do you have any upcoming court cases?
*
Yes
No
Are you in paid employment?
*
Yes
No
Are you currently on sick from paid employment?
*
Yes
No
Comments
*
Submit
Donate
Feedback
Search
Home
About Us
Vision and Values
Our Trustees
Our Reports
Policies
Equality and Diversity
MQM (Mind Quality Mark)
Outcome Measures and Recovery
Our Services
Day Services and Community Opportunities
Peer Support Sessions
Guided Self-Help
Wellbeing
Counselling
Training
Mental Health First Aid
Suicide First Aid
Mental Health Awareness Training
Courses
Anger Management
Re-Thinking Anxiety
ACTivate Your Life
PMHSS Courses – Stress Control
PMHSS Courses – Understanding Me
Other Services
LGBTQ+
Work With Us
Vacancies
Volunteering Opportunities
Co-production
Suicide Prevention
The Mind Shop
Support Us
Fundraise for us
Our Fundraisers
Donate
A Gift in your Will
#MoveforMITV
News
Contact Us
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Posted on: 9th June 2021
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