Reel Minds Participant Sign-Up Form

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First Name *

Last Name *

What is your date of birth? *

Email Address *

Mobile Number *

Is there a better time of day to contact you by mobile phone? *

Mon. - Fri. (Mornings Only)

Mon. - Fri. (Afternoons Only)

Mon. - Fri. (Any time between 10am - 6pm)

Mon. - Fri. (Evenings Only; 6pm - 8pm)

No - Please don't contact by Mobile; eMail Only

Address

Address 2 *

City/Town *

Local Authority *

Postcode *

Current Valid Driving Licence *

Own Transport *

Please tell us about any medical conditions you have (for First Aider) *

Please tell us about any allergies you have. *

Do you consider yourself to have a disability? *

If you do consider yourself to have a disability please specify below.

Emergency Contact Name *

Emergency Contact Phone Number *

In general, how would you rate your overall mental or emotional health? *

Excellent

Very Good

Good

Fair

Poor

Required

What types of mental health related services have you used? (Select all that apply.) *

None

Individual therapy or counselling

Group therapy or counselling

Technology-mediates services (apps related to mental health)

Other

Required

If other please specify

Do you want to do the Mental Health Awareness course? *

Yes

Required

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