MHELO is a network of people in Gloucestershire with lived experience of mental ill health.  We are affiliated to Inclusion Gloucestershire, and provide opportunities for people with lived experience of mental ill health to work together to have a voice and help improve mental health services and wellbeing in the county.

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* 1. Please tell us how in which way you would like to be involved in MHELO?

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* 2. Name

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* 3. Telephone Number

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* 4. Email Address

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* 5. Which social media do you use

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* 6. Which apps do you use to communicate

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* 7. Which area of Gloucestershire do you live in?

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* 8. Are you interested in attending face to face group meetings?

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* 9. Are you interested in attending virtual meetings using Zoom etc?

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* 10. Date of Birth (DD/MM/YYYY)

Date

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* 11. Ethnicity

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* 12. Please tell us about anything we could do to help you become more involved OR other information you feel would be helpful for the group to be aware of e.g. your work situation, support needs, your health and wellbeing, communication needs, emotional support, or if you simply need a friendly face to help you through the door.

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* 13. What topics particularly interest you? The reason we are asking this is so that we can approach you when these topics are being explored and developed in order to gain your views (tick all that apply to you):

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* 14. Are you involved with any other organisations in relation to mental health? If so, would you mind telling us which ones?

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* 15. Do you identify as (please tick all that apply to you):

Thank you for completing this form. Your information will be held safely and securely by MHELO and Inclusion Gloucestershire for a period of 3 years from the date you complete the form. Your personal information will not be shared with any other parties although anonymised data regarding the living localities, communication preferences, age and ethnicity and areas of interest of our members will be collated and used to guide our involvement with you and others.

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* 16. How did you hear about us?

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