Regional offices (hubs) Publications

Become a member of FACTOR online

FACTOR online membership form

Name

Address

Telephone

email address

About you

Are you?

male
female

How old are you?

If you don't mind, please tell us your date of birth.

Do you have a disability?

yes
no

If yes, please describe your disability.

What is your ethnic group?

We want to ensure we reach carers from different cultural backgrounds.
Choose ONE section from A to E, then tick the appropriate box to indicate your cultural background

A. White

British
Irish
any other white background

Please specify

B. Mixed

white and black Caribbean
white and black African
white and Asian
any other mixed background

Please specify

C. Asian or Asian British

Indian
Pakistani
Bangladeshi
any other Asian background

Please specify

D. Black or black British

Caribbean
African
any other black background

Please specify

E. Chinese or other ethnic group

Chinese
any other background

Please specify

Any other mixed background

I prefer not to answer this question.

Optional section for people who want to be actively involved in research

This part of the form is only for people who want to be actively involved in mental health research projects through FACTOR. Please only answer the questions below if that applies to you.

Do you have any previous experience of being involved in mental health research, or mental health services?
This could be as part of paid work, or on a voluntary basis.

yes
no

Please describe any activity and date.

Have you completed any training which could be relevant?
This can include professional training in health or mental health, and courses in further or higher education.

yes
no

Please let us know about courses and the dates.

Please tell us why you are interested in mental health research.

About the person/people you support

How long have you been/were you a mental health carer?

Please tell us your relationship to the person/people you support
- for example, are you their mother, partner, child or neighbour?

Your relationship to each person:

Name of person (1)

I am their (1)

Their date of birth (1)

Name of person (2)

I am their (2)

Their date of birth (2)

Name of person (3)

I am their (3)

Their date of birth (3)

Data Protection

The information you give us is kept on a database of carers to which only FACTOR has direct access. We need to know if you are happy for FACTOR to pass on your contact details to other NIHR MHRN staff, and if you are happy for FACTOR to pass on your contact details to mental health researchers.
We will not pass on your contact details to other carers or service users.

A record will be kept in the carer database of any activities you undertake for the NIHR MHRN or associated research projects.

Please tick those that apply to you

I am happy for FACTOR to pass on my contact details to other NIHR MHRN staff.
I am happy for FACTOR to pass on my contact details to mental health researchers.
FACTOR must get my agreement before passing on my contact details to other NIHR MHRN staff or mental health researchers.

Today's date

If you prefer to fill
in a form by hand

Download a membership form here, fill it in and return it to:
FREEPOST Plus
RSCK-GSTZ-TJYY
MHRN FACTOR
PO77, Institute of Psychiatry
16 De Crespigny Park
London SE5 8AF

Become a member of FACTOR online

FACTOR online membership form

About you

What is your ethnic group?

Optional section for people who want to be actively involved in research

About the person/people you support

Data Protection

If you prefer to fill in a form by hand

If you prefer to fill
in a form by hand