Expression of Interest Capture Form

North Staffordshire Wellbeing Recovery College Registration Form

Your Personal Details

Title

First Name

Middle Names

Last Name

Date of Birth

/ /

Address

Town/City

Postcode

Landline Telephone Number

Mobile Number

Email Address

Confirm Email Address

Emergency Contact We will contact you using your preferred method of contact however if we need to contact you by another method, for example in an emergency, we will use the other contact details

Emergency Contact Title

Emergency Contact Name

Emergency Contact Number

Emergency Contact Relationship

About You

Primarily, in what role will you be using the Wellbeing College? As a:

Name and address of your local doctor or GP practice

Would you like to tell us more about the services you access? Please tick the boxes for any statements that apply to you:

Inpatient mental health wards
Community outpatient mental health appointments
Talking Therapies
Physical health appointments (i.e. long term health condition)
Community support organisation (i.e. Changes, The Dove Service, JustFamily CIC)

How did you hear about us?

Workshops

Areas of interest

Once you have submitted your form, we will be in touch to arrange an initial chat to discuss your enrolment and book you on any workshops of interest.

How would you like to be reminded of your upcoming workshop bookings? If you choose email, please ensure to include your email address on the Your Personal Details section above

Email
Text/SMS

Your preferred location for attending courses?

Supporting You

Please help us identify your support needs with a brief description of the challenges you have faced or may be addressing through current contact with health services:

Please tell us if you have any additional learning needs or access needs that you would like us to be aware of

Do you consider yourself to have a disability as defined by the Equality Act 2010?

Yes No

Are you a member of the UK Armed Forces community?

After submitting this form a member of College staff will contact you to discuss your enrolment.

Equality and Diversity Monitoring

Combined NHS Trust has a legal responsibility to pay due regard to: eliminating discrimination, advancing equality of opportunity and fostering good relations between people of different groups.

To help us to do this it is important we have a good understanding of how the courses run by the Recovery College are being taken up. With up-to-date and accurate information, we are able to:

Better understand our service users & shape the College's services to meet their specific needs

Identify & tackle any issues different people may have when accessing the courses

Ensure that people who need our services the most are able to access them

Your replies will not be used in a way that identifies you however they will help us to understand how community needs may vary; and helps us make informed decisions on how we develop services and target resources.

Gender

Age Group

Marital Status

Sexual Orientation

Faith Affiliation

Other Faith Affiliation

Ethnic Background: How would you describe yourself?

Confidentiality and our promise to you

Thank you for completing this registration form.

Students of all our workshops are expected to:

maintain the privacy and confidentiality of other students and staff.
not to use mobile phones, computers or recording devices during workshops (unless agreed prior to the day).
inform us as soon as possible if you are unable to attend.

In return the Wellbeing College will:

ensure the data you have provided us above is kept within GDPR regulations. Your personal data will not be shared outside of the Wellbeing College without your consent; unless in exceptional circumstances where we have concerns about your or others' immediate safety. In all cases our primary aim will be to obtain your permission first.
offer courses FREE
involve our service users in the development of our College wherever possible.

By submitting this enrolment form, you are confirming that you have read and understand how your information will be stored / shared by the Wellbeing College

I agree to the above

Yes No