Sign up form

Name / Enw *

Family name / Enw teulu *

Address line 1 / Llinell Cyfeiriad 1 *

Address line 2 / Llinell Cyfeiriad 2

Town / City / Tref / Dinas *

County / Sir *

Postcode / Cod Post *

Email / Cyfeiriad e-bost

Telephone number / Rhif ffôn *

Preferred language / Iaith ddewisol *

English / Saesneg

Welsh / Cymraeg

I am aged 18 + / Rwy'n 18 + oed *

Who are you filling in this form for? / Ar gyfer pwy ydych chi'n llenwi'r ffurflen hon?

Myself / Fi

A patient (Primary care or allied health) / Claf (gofal sylfaenol neu iechyd perthynol)

A local Mind service user / Defnyddiwr gwasanaeth grŵp Mind lleol

Do you hold consent from the individual for us to contact them? A oes gennych ganiatâd gan yr unigolyn i ni gysylltu â nhw? *

Yes/oes

No/Nac ydw

What is your name? / Beth yw eich enw? *

What is your email address? / Beth yw’ch cyfeiriad e-bost? *

I understand that supported self-help is not an emergency service and that if I feel that I need urgent help I can call the Samaritans on 116 123, visit my GP or local A&E department / Rydw i’n deall nad yw hunangymorth â chefnogaeth yn wasanaeth argyfwng, ac os rydw i’n teimlo fel rydw i angen help ar frys, rydw i’n gallu galw’r Samariaid ar 116 123, ymweld â fy meddyg teulu neu fynd i fy adran Damweiniau ac Achosion Brys lleol. *

I understand that by sharing my phone number I give consent for a local Mind practitioner to call, text or leave a voice message about Supported self-help. / Rwy'n deall fy mod, trwy rannu fy rhif ffôn, yn rhoi caniatâd i ymarferydd Mind lleol ffonio, tecstio neu adael neges lais am hunangymorth â chefnogaeth. *

Active Monitoring