Child and Adolescent Registration Form

Title*
Name*

First

Last
Address*

Street Address

City

ZIP / Postal Code
Age*
Do you use Child and Adolescent Mental Health services (CAMHS) or have done in the past?*
- Yes
- No
Telephone number*
Mobile phone number
Email address

To reduce costs, it would be helpful if we could by email. Please leave blank if you do not wish to be contacted by email.
Is your Parent/Carer aware you are wanting to join this group*
- Yes
- No
Contact number for your Parent/Carer*
Please tick if you are a staff member referring a young person with their consent
How will my information be used?
How will my information be used?
- When you send us this form you are giving us permission to contact you with information about ways to get involved
- We will store your personal information securely, in line with NHS guidelines
- We will only share your information if necessary and we will always ask your permission
- You can remove your name from our contact list at any time.

How will my information be used?