Prospective clinic client form

I confirm I am aged 18 or over.This service is for people over the age of 18 years old. If you need support and you are younger, please visit www.forwardthinkingbirmingham.nhs.uk.

Yes

Do you need urgent help to stay safe today, or are you in immediate danger right now?Our Clinic is not an emergency service and if you are currently in Mental Health crisis, please seek immediate support from one of the following services: Call 999 or visit A and E in the event that your life is at risk; call 111, the NHS urgent mental health helpline; call your GP, if in opening times

Contact details

First name

Surname

Telephone number

Can we leave a voicemail?

Yes

Can we text you?

Yes

Email address

Please provide a brief description of what you'd like support with

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I consent to having this website store my details so that someone can response to my query.