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Thank you for your interest in becoming a trainee within our social enterprise, we would like to invite you to complete this application as thoroughly as you can.


Which project are you interested to join?:

How did you hear about us?:

PERSONAL DETAILS




Date of Birth (Please enter as dd/mm/yyyy):
Gender:
Gender - self description:




Current Address

Postcode:
Borough:

We require the details of a person to contact in case of emergency as well as GP details.

Emergency contact details
Name:
What is your relationship to them?
Phone Number:
Email:
Address:

GP details

GP Surgery:
GP Name :
Referee details

In order for us to process your application we need you to supply the details of someone who has recently been supporting or working with you and that we can contact for further information.

First Name:
Last Name:
Referee Organisation and Department:
What is your relationship to them?
Referee Address:
Referee Phone number:
Referee E-mail:

MENTAL HEALTH

Have you ever been admitted to hospital experiencing mental distress? :
Please give us some details about your hospitalisation(s):
Have you ever been diagnosed with a mental illness?
If yes, what was the diagnosis?
Have you ever been prescribed medication for mental health issues?:
If yes, please give details:
Are you currently taking any medication?
If yes, please indicate the medication(s) you are taking
Can you describe your current mental health and how you manage it?

OCCUPATION

Please indicate your current employment status:
Please tell us about any past work that you have done and your hobbies/interests?

AVAILABILITY

Please select which days you are available:

Monday:
Tuesday:
Wednesday:
Thursday:

OUTCOMES FOR PLACEMENT AND SUPPORT NEEDS

What are you looking to get out of the placement?

Job skills:
Motivation:
Increase Stability / Develop Routine:
Improve Confidence:
Social Skills:
If you have further expectations about the placement, please provide details:
Do you consider yourself to have any disability?
If yes, please give details:
Do you have any audio or visual impairment or mobility issues?
If yes, please give details:
Do you have any other support needs?
If yes, please give details:

***Optional: you do not need to fill in the following questions if you do not wish to, however we appreciate if you do, as it helps us to ensure that our services reach the widest possible audiences and that they are available to sections of the public that may be underrepresented. ***


Ethnicity:
Religion or Belief:
Other Religion or Belief:
Sexual Orientation:
Other Sexual Orientation:

CONSENT

Type your name to confirm that you wish to apply for a trainee placement with The Centre for Better Health