First name*

Last name*

Preferred name (if different)

Date of Birth*

Gender identity

Phone number*

Email address*

NHS number (if known)

Address line 1*

Address line 2

Postcode*

County*

Town/City*

Medical conditions we should know about

Learning needs or support with reading/writing

Adjustments to help you take part

Any risks we should know about

Have you ever, or are you currently, experiencing mental health difficulties?

If yes, please share as much or as little as you wish (optional)

GP appointments

Number of appointments

Mental health nurse appointments

Number of appointments

Social worker appointments

Number of contacts and reason for attending

Community mental health team contacts

Number of contacts and reason for attending

How many A&E visits have you had due to mental health?

In the last 3 months have you been admitted to hospital as an inpatient?

How many days were you in hospital?

Number of appointments

Accommodation Type

Employment/education status

Do you consider yourself to have a disability?

Main Disability

Are you a carer?

Do you have a carer supporting you?

Ethnicity

Sexual Orientation

How did you hear about the Recovery College?

Is this a self referral?

Date of Referral