Pathways to Better Health is only able to accept self-referrals. If you are an organisation and are supporting a young adult to complete this form, please contact us before proceeding at pathways@centreforbetterhealth.org.uk or 0208 9853570 (and ask to speak with Pathways to Better Health)

If you are 18-25, living in City and Hackney, and are struggling with low wellbeing or your mental health, you've come to the right place.

Whilst not a counselling or therapy service, we can offer a safe, supportive space to talk about how you are feeling and provide practical support to help. Our team will work with you to set and manage goals according to your needs and aspirations.

Just fill in this short form and someone from our team will get back to you.

If you are currently under secondary care, we would be grateful if you also put us in touch with your care coordinator by sending an email to pathways@centreforbetterhealth.org.uk.

Date of birth (please enter as DD/MM/YYYY):

Gender:

Gender Self-Description:

Employment Status:

Current Address

Phone:
Mobile:

Can we leave a voicemail?:

How would you prefer we contact you? :

To select multiple options:
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Please provide the details of a person to contact in case of emergency. This can be someone who is supporting you through another service, or a friend or family member. Please ensure that the emergency contact is someone who is often available

Emergency contact:

Emergency contact relation to you:

Emergency contact phone number:

If you have not been able to provide the details of an emergency contact, please provide details of your GP. We require either an emergency contact or details of your GP in order to proceed with this application.

GP Surgery Name:

GP Surgery Address:

Please provide any details of your education and work history:

Please briefly describe your current mental health and wellbeing, any experiences you have had that may have impacted this, and any other information you feel we need to know. We understand that it may be hard to share this. Your response is confidential and will help us to assess your application:

Have you ever been admitted to the hospital experiencing mental distress?

If yes, please give details:

Have you ever received a mental health diagnosis?

If yes, what was the diagnosis?:

Have you ever been prescribed medication to support your mental health?

If yes, please give details:

Are you currently taking any medication to support your mental health?

If yes, please give details:

Do you use, or do you have a history of using, substances/alcohol?

If yes, please give details:

If you have been referred to, are currently accessing, or have recently received support from another organisation or service, please list which one(s) here:

How have you been feeling over the last week?

To help us better understand your thoughts, feelings and activites over the last week, we ask that you complete a short self-report measure called the ReQol (Recovering Quality of Life). Please complete the form by clicking on the link here*. Please note that we will not be able to proceed with your application without this information.

*This form will take around 3-4 minutes to complete.

We are committed to ensuring that the clients and volunteers we work with reflect the diversity of our community, and that barriers that prevent underrepresented groups from accessing our services are gradually identified and removed. To help us to do this, we encourage you to answer the below questions.

How did you hear about our service?:

Ethnicity:

Ethnic Category - Other:

Religion or Belief:

Other Religion or Belief:

Sexual Orientation:

Other Sexual Orientation:

Housing Status:

Other Housing Status:

Experience of criminal justice system:

Inclusion

Do you have any disability, audio or visual impairment, mobility issues or any other support needs?

If yes, please give details, including any reasonable adjustments you may require. :

Data Protection

The Centre for Better Health needs to collect this data about you in order to establish if we can provide you with an appropriate service. We will use the information that you have provided in accordance with the Data Protection Act 2018. You can read our Privacy Notice for information on how we handle this data.

Please type your name below to confirm that you agree to your data being stored and processed by the Centre for Better Health.

City and Hackney Wellbeing Network

If you live in the City of London or London Borough of Hackney, you may be eligible to join the City and Hackney Wellbeing Network. As a member of the Network, you could access courses and groups at the Centre for Better Health, free of cost to you.

I would like to be contacted by email about joining the City and Hackney Wellbeing Network: