Mental Health Enquiry Form

Permission to Share Information/Make Enquiries:
Amicus Trust aims to provide a single point of access to a range of short term housing related support services across England. In order to do this, we need to ensure that as much information as possible can be shared between agencies about your needs. All information shared will be treated as confidential and shared only with those who need it (see Data Protection statement below). By completing this form you agree to these conditions .

Data Protection Information
Amicus Trust (a registered charity (268639) and a company limited by guarantee (1182060)) processes your information in order to pursue its legitimate interest to provide support services for victims of homelessness. Where you provide us with data concerning your health, sexual orientation and criminal offence these are processed based on a substantial public interest to safeguard individuals at risk. We also ask for your ethnic background to ensure equality of opportunity or treatment. If we do not have access to this information, we may be unable to provide you with the full range of services to support you.

Your data may be shared with organisations who will assist in assessing your needs, including those listed on this form, other local authorities and health agencies.

Your personal details held by Amicus Trust will be processed in a manner that ensures appropriate security of the personal data, including protection against unauthorised or unlawful processing and against accidental loss, destruction or damage, using appropriate technical or organisational measures

We will only keep personal data for as long as necessary to provide the service and will anonymise any remaining data for statistical purposes after we stop providing support.

For information about your rights, including raising a complaint, please see -

For complaints, to exercise a right or other queries, please contact 01234 358478

For details of our privacy policy please see

Details of person applying / being referred
Support areas of interest
Background information
Drug / alcohol intake
Known risk factors
Other relevant information