Application Form

Our Criteria: We work with adults who are managing mental health conditions, such as depression and anxiety, but you don’t need a diagnosis. Our sessions are free to those not in work, and also to those working or furlouged in return for a small donation to our work.

We need a little bit of information from you, so we know how we can best help. You can use this form to access any of our services. Please tell us which of the online sessions you wish to attend. (You can attend all sessions or specific ones) in the “What would you like to achieve with us box”.

Our work is suitable for you if: 

1.  You are ready to make some changes in your life.

2.  You are not in crisis and are open to new ideas and looking forward.

3.  You are committed and can attend the sessions you register for.

Your information will not be shared and will only be used to carry out our work with you.

We will get back to you as soon as we can.

Please wait...

First Name

Surname

Alternative name

Address line 1

Address line 2

Address line 3

Address line 4

Address line 5

Postcode

Phone

Mobile (12345 123456)

Email Address

Date of birth (dd/mm/yyyy)

Unemployed Please Select... Yes No

Are you working under 16 hours a week? (If no above) Please Select... Yes No

Do you have any disabilities or learning disabilities? Please Select... Yes No

Type of disability (If yes above)

Anxiety
Depression
Personality Disorder
Other Mental Health
Mobility disability
Visual impairment
Hearing impairment
Other physical disability
Autism/Asperger
Dyslexia
Literacy
Other Learning difficulty
Other

Where did you hear about our work? Please Select... Self-referral Statutory Local Charity National Charity Other

If referred, contact details of the referrer

Please tell us a bit about yourself and what would you like to achieve with us?

Please tell us what you are applying for (name of the session(s) or coaching)?

Ethnicity Please Select... White UK White Non UK Gypsy or Traveller Other White background Indian Pakistani Bangladeshi Chinese Other Asian background Black African Black Caribbean Other Black background Asian Mixed/Other ethnic background

Have you received any other support from another organisation in the last 2 years? Please Select... Yes No

If yes, please tell us which one(s)

Religious belief Please Select... No religion Christian Buddhist Hindu Jewish Muslim Sikh Other religion Prefer not to say

Sexual Orientation Please Select... Heterosexual Lesbian/Gay/Bisexual Prefer not to say

Have you ever experienced domestic violence, physical or psychological abuse in the home? Please Select... Yes No Prefer not to say

Have you ever experienced bullying in the home or workplace? Please Select... Yes No Prefer not to say

Gender Please Select... Male Female Gender Neutral Other

Enter your details here: