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Expression of Interest - Your details

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  • Email
  • Home Phone
  • Mobile
  • Text/SMS
  • Post
Yes No

About You

Yes No
Yes No
Yes No
  • Service User
  • Carer
  • Relative/Friend
  • Professional / Staff
  • Member of the Public

Your Chosen Course

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:

  • Blind/sight impaired
  • Deaf/hearing impairment
  • Dementia (eg. Alzheimer's Disease
  • Developmental disability (eg. Asperger's Syndrome, autism)
  • Dyslexia
  • Emotional or behavioural issues/difficulties
  • Learning difficulty or disability
  • Mobility impairment (eg. wheelchair user)
  • Substance abuse issues (alcohol, drugs)
  • Other including unseen illnesses (eg. diabetes, epilepsy) - please state:

Your Requirements

Student Declaration

Equality and Diversity Monitoring

Yes No Prefer not to say
Yes No Prefer not to say
  • Mental Health (including depression or anxiety)
  • Asperger's Syndrome/autistic spectrum
  • Blind/sight impairment
  • Deaf/hearing impairment
  • Dementia (eg. Alzheimer's Disease)
  • Learning difficulty or disability (eg. dyslexia)
  • Mobility impairment (eg. wheelchair user)
  • Unseen illness (eg. diabetes, epilepsy)
  • Other (please specify)
  • Prefer not to say
  • I do not have a disability

Participation in Research

Yes No
Yes No

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