START

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 our placements?:

PERSONAL DETAILS



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


Can we leave a message?
Address
Street:
Postcode:
Borough:
Is this your home address?:
If you have indicated No, please provide your home address below
Home address
Street:
Post Code:
Borough:
Emergency contact details
Name:
Phone Number:
Email:

GP details


Name :
Phone number:
Address:

MENTAL HEALTH

Have you ever been admitted to hospital experiencing mental :
Please give us some details about your hospitalisation(s):
Have you ever been diagnosed with a mental illness?
If yes, what was the diagnosis?
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?

OUTCOMES FOR PLACEMENT AND SUPPORT NEEDS

What are you looking to get out of this placement?

For Windows: Hold down the control (ctrl) button to select multiple options
For Mac: Hold down the command button to select multiple options


Other Expectations:
Do you concider yourself to have any physical disabilities? if yes, give some details:
Do you have any audi or visual impairment or mobility issues?
Do you have any other support needs?
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:
Role in Relation to Applicant:
Referee Address:
Referee Phone number:
Referee E-mail:

***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. This part of the application will be kept separately and anonymously for monitoring purposes only.***


Ethnicity:
Ethnicity Sub Category:
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 placement with The Centre for Better Health