Thank you for your interest in finding out more about what the Enfield Wellbeing Network has to offer – whether you are an Enfield resident who would like to join us or are getting in touch on behalf of someone else.

You can either complete the form below, or if it’s easier call us on 020 3827 2840.

When you send this form you will get an email confirming the details you have submitted. A member of our health and wellbeing team will get in touch with you later to find out how we can support you – or the person you are referring to us.

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I am filling this form in: *

• For myself – I would like to join the network to improve my health and wellbeing
• For a friend or family member – and they are happy for me to get in touch on their behalf
• Because I am a health or care professional referring a client or patient

Please choose one option. If you are filling the form in for someone else, you will be able to add their name in a box that will appear after you have chosen one of the options.

If you are filling the form in FOR SOMEONE ELSE please tell us their name here

First

Last

I can confirm that this person has given me permission to fill the form in on their behalf

• Yes, the person I have named has given me permission to fill this form in and submit their details to Enfield Wellbeing Network

Your contact details

Your name *

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Last

Please tell us your own name

Your email *

Email

Confirm Email

Please put YOUR OWN email address here, even if you are filling the form in for someone else. We will use it to send you a receipt for this form and to get in touch about your enquiry

Your phone

Please put YOUR OWN phone number if you would like to be contacted by phone, even if you are filling in the form for someone else

Your organisation

Professionals who are referring a patient or client should state the organisation they work for

Please give us a bit more information to help us put the right health and wellbeing worker in touch with you…

Please tick all the boxes that apply to you

• I am aged between 18 and 50 years old
• I am over 50 years old
• I am a carer (looking after an adult family member or friend)
• I am interested in finding out more about support for my mental health
• I currently receive care through Enfield Council

Please tick all the boxes that apply to the person you are filling in this form for or referring to us

• They are aged between 18 and 50 years old
• They are over 50 years old
• They are a carer (looking after an adult family member or friend)
• They are interested in finding out more about support for their mental health
• They currently receive care through Enfield Council

Thank you for filling in the form. Please click the Submit button to send it to us

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