By completing this form you are consenting to the Health and Wellbeing College having access to your clinical records.(Required) Yes Contact detailsYour Name(Required) First Last Preferred name First Date of birth(Required) DD slash MM slash YYYY Preferred pronounPlease select from the listHe / himShe / herThey / themOtherIf other, please specifyYour Address(Required) Street Address Address Line 2 City or Town Postal code Your phone number(Required)Your email Name of GP surgery(Required)Address of GP surgery Street Address Address Line 2 City or Town Postal code The college mainly uses email however if you prefer information to be sent via post please tick this box Yes We may need to contact you for further information. Please state your preference for communication.(Required) Text Phone Email Name and phone number of a personal emergency contact e.g. family member, friend, partnerThis person would be contacted in the event of an emergency e.g. you become physically or mentally unwell during the course.NamePhone numberRelationship to that person Add RemoveWhere did you hear about Gloucestershire Health and Wellbeing College? Social media GP surgery Mental health team Physical health team Waiting room Other If other, please specifyMental 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?Please select from the listRecovery Team in GloucestershireAOTGRIPPerinatalLater LifeEating DisordersInpatients at Wotton LawnInpatients at MontpellierInpatients at Laurel HouseInpatients at Charlton LaneInpatients at HoneybourneSelect which course/s you are interested in enrolling onto Creative Course Life Skills for Independence Mindfulness Workshop for Mental Health and Wellbeing Coping with Winter Employment Course Preparing for Discharge and Next Steps For information about our current courses, please click here Physical health courseFor a place on Live Better to Feel Better course, you must be 18 years or over, have a Gloucestershire GP and one or more long-term physical health condition(s).Which long-term physical health condition/s have lead you to apply for this course?Are there any other physical or mental health conditions you are living with that we should know about?Please select ALL locations you can travel to for a course Gloucester Cheltenham Tewkesbury Forest of Dean Cirencester Stroud Online 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 supportParticipants 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?Please list symptoms and triggers.At these times what is helpful? What is unhelpful?Do you have any allergies?(Required) Yes No If yes, what are you allergic to?Do you have any access or mobility needs? Yes No E.g. wheelchair userIf yes, please specifyLearning support requirementsPlease let us know if you have any learning support needs. For example, do you need help with reading or writing, visual or hearing impairment etc.Please detail any learning support needs below.Is a translator required?(Required) No Yes - please arrange a translator for me Yes - I will provide my own translator Please tell us which language.Equality Act 2010The Equality Act 2010 protects disabled people, including those with long-term health conditions, learning disabilities and non-visible 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?This information may help us make any adjustments necessary for you. 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.Is there anything else we should know to help us support you during the course?CAPTCHA