• Coventry & Warwickshire Mind > Recovery & Wellbeing Course Registration
  • Recovery & Wellbeing Course Registration

    Recovery & Wellbeing Course Registration

     

    Courses I would like to register on:*

    Are the course/s based in Coventry or Warwickshire?*

    Contact details:
    Title

    Forename/s*

    Surname*

    Address*

    Postcode*

    Contact Email Address*

    Telephone Number*

    Are you happy for us to leave a message on these numbers?*

    Equality details:
    Please help us abide by the Equality Act 2010 by answering these questions:
    Gender*

    Do you live and work in a gender other than that assigned at birth?

    Sexual Orientation

    Ethnic Origin

    Are you disabled?

    if yes, what is your main disability?

    Do you have any specific communication needs?

    Emergency contact details:
    Name

    Relationship

    Contact number/s

    Other Support
    Are you currently seeing any NHS professional?*

    If yes, please tell us about them:

    Do you attend the recovery partnership

    Who is your GP?

    GP Surgery?

    Please tell us about any physical health issues you have and how we should respond in an emergency?

    Information Sharing
    Declaration (please tick the box to confirm)

    I confirm that I am happy for CW Mind to share or exchange information about me, on my behalf, other than the organisations or services I have mentioned below.

    Organisations or services I would NOT like CW Mind to share/exchange information with:

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