Tell us about your feelings or concerns by filling in the form below

Response times

You can use this form to contact us at any time. Once we receive your message, we will respond to you as soon as we are able – this is usually within two working days.

*these fields need to be filled in

How much will it cost?

The service is free to anybody who lives in Nottingham City. It will not cost you anything.

What can we help with?

Helping you to understand what you’re experiencing
Helping you find and access the services that may help you
Helping you to improve your well-being and resilience.

Tell us how you are feeling
We may be able to help. We don’t need to know everything, just a few reasons about why you are contacting us.*
About you

Tell us more about you so we can talk. This data is confidential and we will not share personal information with any other organisation or individual.
Your Name
Date of Birth
Your telephone/mobile number
Your Email address*
Your first language
Are you happy to be contacted by phone?
Postcode*

About the Referred

Please provide as much information as possible. This data is confidential and we will not share your information with any other organisation or individual.
Name of Referred
Date of Birth
Telephone Number
Address Line 1
Address Line 2
Postcode
First Language
Does the referred prefer to be contacted by phone?
How did you hear about the service?
Ethnicity (please state)
Marital status (please state)
Gender
Gender reassignment
Religion (please state)
Sexuality
Referrer Details
Name of Referrer
Referrer Telephone Number
Referrer Email Address
Referral agency and address
Do you consider yourself to have a physical disability yes/no. (If yes please state what it is)
Are you a carer
Referral taken by: (please state name)
GP Details
Name of GP
GP Address Line 1
GP Address Line 2
GP Town/City
GP Postcode
GP Telephone Number
Other Support
Other Support
Other Support Address Line 1
Other Support Address Line 2
Other Support Town/City
Other Support Postcode
Other Support Telephone Number
Other Support Email Address
About the Referral
Are you aware of any risks to yourself or to others: if so, please state
Reason For Referral: (wellbeing and mental health at present time, please include medication)
Primary Reason for Referral
Primary Reason Other Details
Secondary Reason for Referral
Secondary Reason Other Details
What type of group or social activities would you prefer?
Email
This field is for validation purposes and should be left unchanged.

Your confidentiality

Any information that you give to Wellness in Mind for yourself or on behalf of someone else will remain with the Wellness in Mind Team and will not be shared with any third parties without your full consent.

We will only use the information you provide to assess your enquiry/ referral and give you information that could help you address the issues, such as connecting you to specialist services or supporting you to access other services.