Apply for a Mindfulness course

Please complete the following information:

NHS Number (if known):

Title (required):

First name (required):

Last name (required):

Date of Birth (required):

Address (required):

Postcode (required):

Preferred contact telephone number (required):

Can we leave a voice message? (required):
YesNo

Can we send you text messages? (required):
YesNo

Email address (required):

Can we contact you by e-mail? (required):
[radio contact-email "Yes" No"]

Ethnicity (required):
WhiteMixedAsian or Asian BritishBlack or Black BritishOther ethnic groupsNot statedNot known

Gender (required):
malefemaleNot knownNot specified

GP Surgery - you must be registered at one of the below surgeries to be eligible for the course (required):
AbbeydaleAdelaide Street SurgeryArnold Medical CentreBloomfield Medical CentreCrescent SurgeryCleveleys Group PracticeElizabeth Street SurgeryGlenroyd Medical Centre (Moor Park)Glenroyd Medical Centre (Whitegate Drive)GP Led Health Centre, Whitegate DriveGrange Park Health CentreHarris Medical CentreHighfield SurgeryLayton Medical CentreMarton Medical PracticeNorth Shore SurgeryNewton Drive Health CentreSouth King Street Medical CentreStonyhill Medical PracticeSt. Pauls Medical CentreVicarage lane SurgeryWaterloo Medical Centre
You must be registered at one of the surgeries above to be eligible for the course.

Do you have a long term medical condition?
YesNo

Have you ever served in the armed forces or are a dependent of someone serving? (required):
YesNo

Are you (or your partner) pregnant or do you have caring responsibility for a child under 24 months?*: (required):
YesNo

Please leave this field empty.

We are sorry...

Your responses to our questions have indicated that Mindfulness may not be the most appropriate treatment for you or that further information is required to identify the most suitable option.

If you are experiencing anxiety and depression then Mindfulness may still be suitable for you. Please contact us on 01253 955700 or email bfwh.healthierminds@nhs.net for further information.

If you are receiving help from another mental health team, please contact them for more information rather than referring to us.

If you are having thoughts about harming yourself or feel you are in crisis and need urgent help today please call 111 or:

• Contact your GP and request an emergency appointment

• Attend the Urgent Care Centre at Blackpool Victoria Hospital

• SHOUT – free 24/7 text service for anyone in crisis anytime, anywhere. Text Shout to 85258

• Phone the Mental Health Helpline on 0800 915 4640 (open Monday to Friday from 7pm until 11pm and from 12 midday to 12 midnight at weekends)

If your main problem is alcohol or drug use, please contact Horizon https://www.horizonblackpool.uk/