Enquiries Capture Form

Relates to required fields

Expression of Interest - Your details

First Name

Middle Names

Surname

Date of Birth

/ /

Address

Town/City

Postcode

Email Address

Contact Telephone Number

Mobile Phone Number

Emergency Contact Name

Emergency Contact Number

Is this your first Registration with our recovery college?

Yes No

How did you hear about us?

About You

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

I use services provided by Sussex Partnership NHS Foundation Trust or I have been discharged from Success Partnership NHS Foundation Trust within the last 6 months

Yes No

Please state which services

I use GP/Primary Care services (including Health in Mind or Time to Talk)

Yes No

Do you currently access mental health services?

Yes No

Which Partner services do you currently access?

Your Chosen Course

Preferred Course 1

Preferred Course 1 Start Date

Preferred Course 2

Preferred Course 2 Start Date

Preferred Course 3

Preferred Course 3 Start Date

Your single preferred location

Supporting you

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

Mental Health conditions and support needs - please give a brief summary

Your Requirements

Any Additional Learning Needs

Inform the trainers

Name and address of your local doctor or GP practice

Student Declaration

Please indicate your status (if relevant)

Equality and Diversity Monitoring

Age Group

Gender

Do you consider (or have you ever considered) yourself to be transgender?

Yes No Prefer not to say

What is your sexual orientation?

If 'other' please specify (sexual orientation)

Which category below best describes your ETHNICITY?

Are you an asylum seeker or refugee?

Yes No Prefer not to say

Which category below best describes your RELIGION or BELIEF?

Other Religion or Belief

Please specify 'other' disability

Participation in Research

I consent to being contacted for research or evaluation purposes

Yes No

Partnership Research Network

Yes No