Mental Health Action Membership Form | Rethink Mental Illness, The Leading Mental Health Membership Charity

Title

First name

Surname

Address

Post code

Telephone number

Email

Preferred method of contact

Which of the following best describes you?

If other, please state here

Are you

What is your date of birth?

Cultural background

If you answered 'Other' to the previous question, please describe here

Would you like us to pass your details on to your local Rethink Mental Illness Group Co-ordinator?

What level of involvement suits you? Select as many as you like.

Receiving Mental Health Action newsletter

Being sent questionnaires and surveys to complete

Attending MH Action meetings in my area of Worcestershire

Attending events for information about changes in mental health services

Being part of focus groups and workshops held across the County

Helpling organise MH Action meetings in your area

Being the lead person at MH Action meetings in your area

Helping to organise County wide events

Meeting the public at events such as World Mental Health Day

Helping raise money for MH Action

Other

If you selected 'Other', please describe below

What stops you from becoming more involved with Mental Health Action?

I don't feel well enough at the moment

I am busy with other committments

I don’t want to get involved and then disappoint people when I need to say no

I have children and have to be available for them

I am a carer and can’t leave home without respite being provided

I have problems travelling away from home

I don’t have the confidence to meet a group of new people

I don’t feel I have the skills needed

Other (describe below)

If you selected 'Other' for the previous question, please describe below

Mental Health Action