LifecraftmembershipAPPLICATION FORM

new member INFORMATION

Thank you for your interest in Lifecraft which is a user led self-help organisation for adults who use or have used mental health services or have experience of mental distress.
To become a Lifecraft member you need to:
  • Read about our services and our Members’ Code of Conduct
  • Complete this application form and return it to usat the above address
  • After we contact your referee, come to an arranged meeting at Lifecraft and tell us a little more about yourself and what you hope Lifecraft can offer you
Please note: all information that you provide will be handled in strictest confidence and will not be shared with anyone else without your permission. All data is held within the Data Protection Act.
PLEASE COMPLETE THE FOLLOWING IN BLOCK CAPITALS
Title: / First name: / Surname:
Date of Birth: / Gender: / Female ☐ Male ☐
Telephone: / Mobile:
☐I do not wish to receive text message updates on Lifecraft’s services, activities and events
Email:
☐I do not wish to receive email updates on Lifecraft’s services, activities and events
Address:
Postcode:
Please indicate which services you are interested in:
Counselling / ☐ / Projects / ☐ /
Courses and Support Groups / ☐ / Volunteering and Member Employment / ☐ /
Groups and Activities / ☐ / Support and Advice / ☐ /

Reference INFORMATION

References should be from people who have known you in a professional capacity for at least six months and have knowledge of your mental health history. This can besomeone like your GP, psychiatrist, social worker or CPN.
Please note: Lifecraft does not have the facilities to support a person with an ongoing alcohol or drug dependency. If you have an alcohol or drug dependency and have been in recovery for 3 months, please provide details of a second referee who we can contact.
First Reference / Second Reference (if there is a dependency)
Full Name
Organisation
Address
Postcode
Telephone
Email
Professional capacity
I confirm that I wish to apply for membership of Lifecraft and that I have given my permission for Lifecraft to write to the person named above to provide a reference on my behalf.
I understand that a copy of this application will be sent as proof of consent.
Print Name
Signed Date
Please return to:
Lifecraft, The Bath House, Gwydir Street,Cambridge, CB1 2LW
If you have an electronic signature email this form to:
We will acknowledge receipt of the completed form within five working days and will keep you informed on the application process