Below is a list of all the questions from our Enquiry Form, provided here for your reference. This page is intended to give you an overview of the form’s contents, making it easier to review the questions in advance.

Please note that this page is for viewing purposes only, and the form can be completed on our Microsoft Forms link either on our home page or for each Service page.

Enquiry Form

Referral Information

Q: Are you completing this form on behalf of someone else?
A: Yes/No

Q: If yes, have you obtained consent to make this enquiry (by saying yes you are giving consent for SWR Mind to store the information held on this form on a secure database and consider the person to have capacity to give informed consent).
A: Yes/No

Q:Referrer’s name (If self referral leave blank)

Q:Referrer’s Organisation (If self referral leave blank)

Q:Referrer’s contact number (If self referral leave blank)

Q:Referrer’s email address (If self referral leave blank)

Q:What is your relationship to this person?
A: Friend, Family, Professional, Other

Q: Which service are you enquiring about?
A: MindSide, MindSpace, MindPath, Wellness Bridge, Rise2Thrive, Our Neighbourhood Befriending, Our Neighbourhood Volunteer Brokerage, Transformative Coaching, Guided Self-Help, Telephone Support, Creative Spaces.

Q: In a few words, please explain how we can help you?

Personal Details

Q: First Name and Last Name

Q: Address and Postcode

Q:Mobile Number and Telephone

Q:We would like to contact you about our services from time to time. You can opt out whenever you like, and we won’t share your contact details with any other organisations. Are you happy for us to contact you
A: Post, Email, Mobile, Text Message, Consent to receive

Q: Date of Birth

Q: Preferred Contact Method
A: Email, Telephone

Q: When is the best time to contact you?
A: Morning (9am – 12pm), Afternoon (12pm – 5pm), Evening (5pm-8pm)

Q: Permission to leave a voicemail message/send a text
A:Yes/No

Q: Emergency contact name and number (parent/guardian if under 16 years)

General Information

Q: Are you experiencing any of the following mental health issues?
A: Anxiety, Depression, Low Mood, Social Isolation, Loss/bereavement, Anger Management etc.

Q:On a scale of 1-10 (with 1 being ‘not at all’ and 10 being ‘very much’) please indicate how much these problems impact on your ability to go about your daily day-to-day life.

Q: Are you experiencing problems/issues with any of the following?
A: Money, Housing, Work, Relationship, Long term health condition etc.

Q: Do you consider yourself to have a disability, neurodiversity or long term health condition?
A: Yes/No

Q: Do you have any alcohol or drug related problems (please specify)
A: Yes/No

Q: Do you take non-prescription drugs?
A: Yes/No

Q: Do you take prescription drugs?
A: Yes/No

Q: Do you have a condition which may affect your memory, ability to learn/process and/or understand information
A: Yes/No

Q:Thinking about your financial situation, which of the below statements best describes your situation?

Q: Are you an unpaid carer (ie, you are not employed as a professional carer)
A: Yes/No/Maybe

Q: Are you a veteran
A: Yes/No

Q: Do you feel isolated or lonely
A: Yes/No

Q:Would benefit from a regular volunteer support call
A: Yes/No

Q: Are you accessing any other mental health services?
A: Community Counselling, Next Steps, Horizons

Q: As an equal opportunities organisation, we would like to ensure we meet your needs; do you have any specific requirements which would assist us to do this?

Q:Do you consider yourself to be a risk to yourself or others?

Q:Do you have anything else you would like us to know?

Q:GP Name and Surgery Name

Q: Where did you hear about the service?

Q: Details of Referral