Please review the following terms of use carefully. If you don’t agree to these terms you should not submit a
registration form.

  • The purpose of the registration form is to gather information about you in order to register you with Open Minds,
    provided by NAViGO.
  • By completing the form it is not an automatic acceptance to the service.
  • You must be registered with a GP in North East Lincolnshire to refer into this service.
  • You will be sent an automatic email to confirm receipt of the referral form.
  • If it is felt that Open Minds can offer you a service you will be contacted to arrange a mutually agreeable appointment
    time and date.
  • If we do not feel that we can offer you an appointment at this time, then you will be contacted by a member of
    staff to discuss this.
  • It may be 7 working days before your registration form is reviewed and for a member of staff to contact you.
    Therefore if you are agreeable to these terms of use you are also acknowledging that you are in a stable
    enough mental state to await contact. If you do not feel able to wait for a response it is advised that you
    contact your GP or the crisis team on 01472 256256. - Select option 3 for Mental Health.
  • Information provided on this form will be kept securely.

Please Note: You must be 16 years or above to complete this form.

A few details about you






YesNo










YesNo

YesNo

YesNo



YesNo

YesNo

Next of kin details








YesNo











YesNo




Details about your GP

Your GP must be within North East Lincolnshire. Any referrals outside of this area cannot be accepted by Open
Minds.




YesNo

YesNo

A few details to know if Open Minds is the right service for you


YesNo

YesNo



A few details about access


YesNo




YesNo

YesNo

YesNo