testurl | Mind in the Vale of Glamorgan

Name

Date of birth

Email

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

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GDPR Consent

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?

Which GP practice are you registered with?

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?

You selected "General wellbeing" - please give us more information below.

Do you have any upcoming court cases?

Are you in paid employment?

Are you currently on sick from paid employment?

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