Contact detailsYour Name(Required) First Last Preferred name First Date of birth(Required) DD slash MM slash YYYY Your Address(Required) Street Address Address Line 2 City Zip/ Postal Code Home phone number(Required)Mobile number(Required)Email Preferred way for the college to contact you(Required) Phone Email Text Post Select AllName and phone number of emergency/crisis contact(Required)ProfessionalPersonal Add RemoveNHS number (if known)Name of GP and surgery(Required)Where did you hear about Gloucestershire Health and Wellbeing College?How were you referred to the college?(Required) Gloucestershire Health and Care team Self-referral Other Which GHC team referred you?Would you like to receive a copy of the college newsletter? Yes No If yes, please indicate how you would like to receive the newsletter: Email Post CoursesDue to the way the college is funded, please be aware that our application criteria varies depending on the course. Enter the course(s) you are applying for in the relevant boxes below, and for mental health courses please include the name of your care coordinator and/or the Gloucestershire Health and Care NHS Foundation Trust (GHC) team you are currently working with.Mental health coursesCourses are open to those receiving treatment from Gloucestershire Health and Care mental health secondary services. This includes GRiP, Assertive Outreach (AO), mental health recovery teams, older adults mental health teams, Eating Disorders team, Specialist Community Forensic team, Perinatal Mental Health team, rehabilitation units Laurel and Honeybourne, Wotton Lawn Hospital and Montpellier Low Secure Unit. If you are unsure whether you meet the above criteria, please contact us for further information.Name of your care coordinatorWhich mental health team provides your care?Select which course/s you are interested in enrolling onto Creative Course Life Skills for Independence Mindfulness Workshop for Mental Health and Wellbeing Recovery Through Activity Physical health coursesTo be allocated a place on one of our physical health courses you must be 18 years or over, have a Gloucestershire GP and one or more long-term physical health condition(s).List ALL long-term health conditions:Select which course/s you are interested in enrolling onto Live Better to Feel Better course - option 1 Live Better to Feel Better course - option 2 A little bit about youTell us a little bit about your health and wellbeing goals.In order to best support your needs, please describe your reasons for applying for your chosen course(s). Practical health and wellbeing supportWe are not a clinical service. However, participants on our courses have a range of health and wellbeing challenges. Therefore, it is useful for us to understand your needs and how we can best support you if you become unwell on our courses.If you were to become unwell, what would we notice? How would we tell?(Both physical and mental health.)At these times what is helpful? What is unhelpful? Who can we contact?The latter might be different to the emergency contact person, depending on need.Do you have any situations or triggers that you find difficult to cope with, so we can avoid them or plan how to manage them with you in advance so you feel safe?Are there any risks associated with being unwell (physical and / or mental health)? If so, what helps?Do you have any allergies? Yes No If yes, what are you allergic to?Learning support requirementsPlease let us know if you have any learning support needs. For example, do you need help with reading or writing, making a commitment to regularly attend, following group agreements? Please detail any learning support needs here:Examples from previous courses include: Having your support worker along for the first session to give you confidence Requiring printouts on different colour paper to help with dyslexia Large-print materials if your eyesight is impaired Telling us you will not be able to speak in an online group session because of anxiety or other reason, so we do not ask you Arranging for religious and spiritual needs to be met Do you have any hearing impairments that we should be aware of? Do you need support with using technology? Monitoring informationHave you ever served in the Armed Forces? Yes No Gender Male Female Trans I do not wish to disclose this I would describe my ethnic origin as: Asian or Asian British Black Mixed ethnic background White Other ethnic group Asian or Asian BritishBangladeshiIndianPakistaniAny other Asian backgroundBlackBlack or Black British AfricanCaribbeanAny other Black backgroundMixed ethnic backgroundMixed White and AsianWhite and Black AfricanWhite and Black CaribbeanAny other mixed backgroundWhiteWhite BritishIrishAny other White backgroundOther ethnic groupChineseAny other ethnic groupI do not wish to disclose thisPlease select the option which best describes your sexual orientation Lesbian Gay Bisexual Heterosexual I do not wish to disclose this Please indicate your religion or belief Atheism Buddhism Christianity Islam Jainism Sikhism Judaism Hinduism Other I do not wish to disclose this Equality Act 2010The Equality Act 2010 protects disabled people, including those with long-term health conditions, learning disabilities and so-called 'hidden' disabilities, such as dyslexia. If you tell us that you have a disability we can make reasonable adjustments.Do you consider yourself to have a disability? Yes No I do not wish to disclose this information If you consider yourself to have a disability, what adjustments would you like to us to make?The information collected will only be used for monitoring purposes. Any reporting of which will be in an anonymised format.Data protection / GDPR (General Data Protection Regulation)Information you provide us with is held on a secure database and only used for administration purposes. You have a right to see the information we hold about you, and to have it corrected if necessary. If you would like to check your information, or to let us know if you have changed your contact details, please email ghwc@ghc.nhs.uk or call 0300 421 4414.Would like to unsubscribe?If you decide you no longer wish to receive any further updates from us, please email ghwc@ghc.nhs.uk or call 0300 421 4414 with a message saying you wish to unsubscribe. CAPTCHA