Application form to request access to your own mental health record

Strictly confidential once completed.

This form may be used if you wish to:

  • send us your request using email or
  • type in the information and then print off to post to us.

Please enter as much information as you can because this will help us to deal with your request as quickly as possible. The boxes will expand as you type into them.

Request access to your own mental health record

Date of birth Required
Gender Required


We always do our utmost to maintain the confidentiality of our patients' records. Unless you are currently an in-patient on one of our wards, we will require you to send us proof of identity by attaching or enclosing a copy of one of the following: Medical Card - Driving Licence - Birth Certificate - Passport - a letter from the DWP/Jobcentre; plus a copy of a utility bill showing your current home address.

Details of records requested

Please provide as much information as possible, but we realise it may be difficult to remember everything accurately. It would be helpful if you could tell us the type of record you are wanting to access; some examples are: medical/consultant's file, in-patient nursing, day service, occupational therapy, physiotherapy, community team, child and adolescent, learning disabilities.

Our fees as set out by the Data Protection Act 2018

Under the Data Protection Act 2018 the Trust will respond to all applications within a month. This service will be provided free of charge unless the request is deemed excessive or repetitive, in which case an administration fee may be charged.

How would you like to receive any information we are able to release to you?

During the COVID emergency, your own health and safety and the health and safety of our staff are important to us. This is why we need to focus on secure electronic processes and reducing paper wherever possible. Please consider receiving records by secure email if you are able to.

How would you like to receive any information we are able to release to you? Required
Paper copies would be posted to you using Royal Mail's Special Delivery which requires a signature on delivery. Would you like us to contact you to arrange a specific day for delivery when we have completed your request?
Do you wish to view your record with a health professional on Trust premises? Required

If you have any queries or need help with completing your application please do not hesitate to contact us either by telephone or by email:

Direct dial: 01332 389131 

Once completed you can either email your form attaching any relevant documents or post to us:


Postal address:
Access to a Health Record 
IM&T and Records 
Kingsway House East 
Kingsway site 
Derby, DE22 3LZ