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Thank you for your interest in the Centre for Better Health's training programme. Our training placements are aimed at adults who are out of work, or in jobs they don't enjoy, and who are struggling with their wellbeing and mental health.
This application form is for third sector organisations or statutory services that wish to refer a client.

Please select which enterprise the applicant is interested in:

PERSONAL DETAILS



Date of Birth (submit as dd/mm/yyyy):

Gender:
Gender Self-Description:
Employment Status:

Current Address




Borough:
If you are from outside of London, please indicate where from below:


Can we leave a voicemail?:

EMERGENCY CONTACT DETAILS

Please provide the details of a person to contact in case of emergency. This can be you, as the referrer, or a friend or family member of the person you are referring. 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 client's 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 confirm that this information has been provided:

REFERRER DETAILS

Please enter your details as the referrer

First Name:
Last Name:
Which organisation do you work for?:
Address:
What is your role in relation to the applicant?:
Phone:
Email:

EDUCATION, WORK AND GOALS

Please provide any details of applicant's education and work history:

Select up to three personal and/or professional goals that the individual being referred would like to achieve as a result of accessing our trainee programme. At least one employment-related goal should be selected.

**To select multiple options:
For Windows: Hold down the control (ctrl)+ select
For Mac: Hold down the command button

Placement Goals:

NEEDS ASSESSMENT - PART ONE

Please briefly describe your client's current mental health and wellbeing, any experiences they have had that may have impacted this, and any other information you feel we need to know:

Has the client you are referring
Ever been admitted to hospital experiencing mental distress?:
If yes, please give details:
Ever recieved a mental health diagnosis:
If yes, what was the diagnosis?:
Ever been prescribed medication to support their mental health?:
If yes, please give details:

Is the client you are referring
Currently taking any medication to support their mental health?:
If yes, please give details
Does the client you are referring use, or do you they have a history of using substances/alcohol?:
If yes, please give details:
Is the client you are reffering currently accessing any other services?:
If so, please list which ones:

For example, mental health, drug and alcohol, housing, employment support services, etc.


NEEDS ASSESSMENT - PART TWO

Quality of Life Questionnaire
To help our team to better understand how the client is feeling, we ask that they complete a short self-report outcome measure called the ReQoL (Recovering Quality of Life). Please ask them complete the form by clicking on the link here* (you may send them the link separately if they are not currently with you). Please note that we will not be able to proceed with the application until we receive this information.
*The form will take about 3 minutes to complete.

RISK ASSESSMENT

To help us assess any risk in relation to the person you are referring, please complete the below risk assessment:

Risk of violence / harm to others:
Risk of suicide:
Risk of other deliberate self-harm:
Risk of self-neglect / Accidental self-harm:
History of alcohol and/or substance abuse:
If yes, is it:

Please provide details of any risks:
Overall level of risk:
Has a risk management plan been developed?:
If a management plan is in place, please give details here:

APPLICANT'S AVAILABILITY

**To select multiple options:
For Windows: Hold down the control (ctrl)+ select
For Mac: Hold down the command button

Which day(s) is the applicant available?:


DIVERSITY MONITORING

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:

Relationship Status:
First Language
Experience of criminal justice system:

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Inclusion
Please note that access to the Better Health Hub is via a small flight of stairs.

Does the applicant consider themselves to have any disability, audio or visual impairment, mobility issues or any other support needs?
If yes, please give details, including an reasonable adjustments they 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:
To submit your application click "SUBMIT"