Enrolment Form - Your details

First NameThis is the name that will be shown on certificates

Surname/family name

Date of Birth

dd 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / month January February March April May June July August September October November December / yyyy 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024

Address

Town/City

Postcode

Landline telephone number

Mobile Phone Number

Email Address

Validate Email Address

Method of contact We will contact you via email except in an emergency. If you do not have access to email, what is your preferred method of contact?

• Home phone
• Mobile phone
• Text/SMS
• Post

How did you hear about us?

Select....FriendHealth care professional - e.g mental health team, GP, psychologist, support worker LeafletOpen Day/event OtherSocial MediaSomeone who already attendedSouthern Health staff communication (inc from RC) Southern Health websiteWellbeing centreWork colleague

If 'other', please specify (hear about us)

Emergency Contact Details We need to have an emergency contact number in order to process your registration form. This cannot be a GP.

Full name of someone who can act as your emergency contact

Their contact number

Relationship of the emergency contact to yourself

About You

Which category best fits your situation?

Select....Service User (Someone who has been under Southern Health Adult Mental Health, italk/Talking Therapies, Steps to Wellbeing in the past 2 years)Staff member/placement studentCarer of a service user (Someone who has been under Southern Health Adult Mental Health, italk/Talking Therapies, Steps to Wellbeing in the past 2 years)Relative/Friend

in the past 2 years have you been

Select....Under a Southern Health Adult Mental TeamiTalkSteps to WellbeingSteps to Wellbeing

Staff / Placement student options

Select....SHFT Adult Mental HealthSHFT Older PersonsSHFT Specialised DivisioniTalk

Employment Status

Select....EmployedNot employedIn full-time education or trainingVolunteerRetired

Which is your preferred type of course?

• face-to-face
• online
• no preference

Supporting you and your requirements

Is there anything else you would like to tell us that would enable us to support you with your learning?

Equality and Diversity Monitoring This information is anonymous and will only be used to monitor who we are engaging with. This will help understand whether we are reflective of the diversity of our population

If you prefer not to answer these questions please tick here

Age Group

Select.... 17-20 21-30 31-40 41-50 51-60 61-70 70+

What is your gender identity?

Select.... Male Female Non-binary Other (please describe below) Prefer not to say

Other (gender identity)

What is your sexual orientation?

Select.... Heterosexual LGBTQ+ Other (please describe below) Prefer not to say

If 'other' please specify (sexual orientation)

What is your ethnicity?

Select....White: BritishWhite: IrishWhite: Gypsy or Irish TravellerBlack: BritishBlack: AfricanBlack: CaribbeanAsian: BritishAsian: ChineseAsian: IndianArabMixed: White & Black CaribbeanMixed: White & Black AfricanMixed: White & AsianAny other background, please describe belowPrefer not to say

Other (Ethnic origin)

Are you an asylum seeker or refugee?

Yes No Prefer not to say

What category below best describes your religion or belief?

Select....No religious affiliationBuddistChristianSikhJewishHinduAny other religion, please describe belowPrefer not to sayMuslim

Other Religion or Belief

Please check this box if you have served in the UK Armed Forces.

Which of the following statements do you identify with?

Emotional or behavioural issues/difficulties

Learning Disability

Blind/sight impaired

Deaf/hearing impaired

Dementia (e.g. Alzheimer’s Disease)

Dyslexia

Mobility disability

Other including unseen illnesses (e.g. diabetes, epilepsy), please provide further information below

Prefer not to say

None

Substance abuse issues (alcohol, drugs)

Please specify 'other' disability

Submit