Enquiries Capture Form

Recovery College Registration Form

Your personal details

Title

First Name

Surname

Date of Birth

/ /

Gender

Address

Town/City

Postcode

Email Address

Contact Telephone Number

Mobile Phone Number

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

And do you belong to another group as well?

Student
Supporter of a student(family,friend, carer)
Staff member
Volunteer spending time credits

How did you hear about us?

Digital Access

Do you have any of the following?

Laptop or PC with home broadband access
Smartphone with home broadband access
Smartphone with downloadable data
Laptop or PC with WIFI dongle

Courses

Preferred Course 1

Preferred Course 1 Start Date

Preferred Course 2

Preferred Course 2 Start Date

Preferred Course 3

Preferred Course 3 Start Date

Preferred Course 4

Preferred Course 4 Start Date

Preferred Course 5

Preferred Course 5 Start Date

Preferred Course 6

Preferred Course 6 Start Date

Care Coordinator Information

If you are a user of services or care for someone who uses mental health services, please give details of the Services/Team that you / they recieve that service from:

Please note that we will contact this team to confirm this information

Note: If your Care Coordinator works with you on a forensic ward and you are currently an inpatient, please ask your Care Coordinator to contact us to provide additional information to complete your enrolment. We cannot confirm your enrolment without further information

Care Coordinator or Named Worker

Care Coordinator Address

Care Coordinator Telephone Number

Care Coordinator Email Address

GP Information

GP Name

GP Address

GP Telephone Number

Special requirements

Medical needs

Physical mobility adjustment or aids

Anything else?

Equality and Diversity Monitoring

Please specify disability

Ethnic origin