Health Creation Mentorship Diploma Training Application Form

Health Creation Coaching and Mentorship Academy training application form for the Health Creation Mentorship Diploma
Comprising:

Module 1: Health Creation Mentorship Training

Module 2: Principles and Evidence for Health and Wellbeing

Module 3: Professional Coaching and Mentorship

Thank you for your interest in becoming a Health Creation Mentor!

Our criteria for student selection are as follows:
- Enthusiasm and commitment to the Health Creation’s holistic health aims
- Personal warmth, wisdom and compassion
- Communication skills with counselling skills qualification or equivalent experience
- Holistic healthcare knowledge and experience either professionally or personally
- Appropriate prior learning experience
- Some relevant illness experience, for example, as a carer for someone with lifestyle or long-term illness
- Personal application of healthy lifestyle habits and holistic self-help as a good role model and representative for Health Creation
- Time available for study of 5-10 hours per week to complete in 12 to 18 months
- Intention and drive to start and maintain a professional Mentorship Practice
- A clean criminal record.
All information provided within this application form will be treated in the strictest confidence and your data will not be shared with any person or business outside of Health Creation.

Please ensure that you sign the declaration at the end of this form to confirm that you have read, understood and agree with our course requirements, terms and conditions.

Once you have submitted your form it will be reviewed by Dr Rosy Daniel and Lead Course Tutor, Sue Caden. Shorlty afterward you will be contacted to confirm whether or not you have been accepted. Once you have been accepted you will be invited for an interview with our Lead Course Tutor.

For any training enquiries please call Course Tutor Sue Caden on 07756 903759·

For technical queries please contact support@healthcreation.co.uk.

For any other queries please contact our Mentor Manager, Ally Phillips at ally.phillips@healthcreation.co.uk.
GDPR Consent

Health Creation collects your data for administration purposes and to build your Trainee Record.

Do you consent to your data being held in accordance with GDPR regulations and the Health Creation Privacy Policy?
Please check the box below to indicate your consent?*

YesOther
Student Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student E-mail*
example@example.com
Mobile Number*

Area CodePhone Number
Phone Number

Area CodePhone Number
Work Number

Area CodePhone Number
Company
Courses*
Please provide a list of your previous academic qualifications, including: GCSE, A Level, Professional Therapy Training, University Degree, Postgraduate Degree and any other relevant qualifications:*
What is your goal for your Health Creation work?*

To Mentor in a preventive healthcare contextTo Mentor the ill and those with long term illnessTo become a Health Creation Consultant and work within organisationsTo become a Health Creation TrainerOther
About your current and past employment:
How many hours per week do you currently work?*
How many hours per week would you like to provide Mentorship?*
Please provide a brief overview of your past employment inclusive of dates:*
What is your reason for wanting to become a Health Creation Mentor?*
Your personal skills and professional experience:
What professional qualifications do you hold?*
When were you last in professional education and what were you studying?*
What communication skills/counselling training have you had?*
What experience of the Holistic approach to health and illness have you had?*

Personal experienceProfessional experienceOther
Are you computer literate?*

YesNo
Do you have access to a computer and the internet?*

YesNo
What skills do you possess that you feel will make you a good Mentor?*
What experience do you have of your own counselling and/or self-development that would give you insight into the Mentoring role?*
What experience do you have in starting and/or running your own practice or business that you feel will help you set up your practice as a Mentor?*
What previous experience do you have of care for those with long term illness, either as a Health Care Professional, or as a carer for a family member or friend that you feel will help to create empathy with the clients?*
Personal qualities, current state and requirements to start a Mentorship Practice:
Please describe the personal qualities that you will bring to the Mentor role:*
Are you strong enough emotionally at present to train and perform the Mentor role?*
Are you well enough physically to train for and perform the Mentor role?*
Do you have you a recent history of mental illness (within the last five years)? *
Are you reasonably stress free at present?*
Have you been subject to any previous professional complaints or do you have any professional complaints pending? *
Do you have evidence of a clean criminal record? *
Please upload any supporting documents such as a recent DBS check below:

Cancelof
Are you able to work from home or a therapy centre in privacy and quiet, fitting the Mentor role comfortably around other employment and family commitments?*
Personal factors which may affect your training and Mentoring:
Please select any or all that apply from the list below:*

Have you ever had cancer or other serious illness?Has anyone close to you ever had cancer or other serious illness?Have you lost anyone close to you with cancer or other serious illness?Have you been bereaved recently?None of the above
If you selected any of the above, do you feel any of these factors may affect your ability to Mentor those going through the experience of bereavement, cancer or other serious illness?
Are there any other personal issues or areas of vulnerability that you feel may be touched for you as you go through the Mentor training process or providing Mentoring itself? *
Is there any other important information about yourself you would like to tell us?
Your requirements:
Please tell us about any disabilities, learning difficulties or anything else that we need to support you with during your training with us?*
Course requirements, terms and conditions:
Are you confident that you can meet the following course requirements? Please tick the boxes where your answer is yes:*

Yes, I am able to attend five training weekends in October, November, January, March and AprilYes, I am happy to have pre-course Mentor sessions from Lead Course Tutor Sue Caden to prepare me for the trainingYes, I am able to pay the course fee of: £3,950.00 either in full or with a deposit of £950.00 followed by 12 instalments of £250 per monthYes, I am able to commit to approximately 5 hours per week of home study over the course of an 18 month period
Additional Comments
Do you understand and agree to the following terms and conditions:
- Your deposit is non-refundable once enrolled for the Mentor Diploma
- You need to study all three modules to achieve the Diploma in Health Creation Mentorship
- If you cannot complete the Mentor Skills Training and withdraw from the training, you will still have access to the Module 2 and 3 trainings that you have paid for
- If you decide after Weekend 1 of Module 1 to leave the course, 50% of the full course fee of £3,950 is payable.
- After Weekend 2, all course fees are payable and non-refundable
- If you are unable to complete your training in the year of enrollment due to serious extenuating circumstances, at the discretion of the Course Trainers you may transfer your fees to a later year group to complete your training
- You agree not to train others as a Health Creation Mentor unless you are trained to do so by Health Creation
- You will not reproduce any elements of the Health Creation training or the Health Creation Programme by Dr Rosy Daniel without permission in writing from Health Creation Ltd.
I First Name Last Name* agree to and accept all of the above terms and conditions.
Declaration:
I would like to apply for a place on the Health Creation Mentor Training.

I have read, understood and agree to abide by the Terms and Conditions relating to the course.

I am able to afford the course fees and I wish to proceed on this basis.
Date*

MonthDayYear
Date
Signature*

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Thank you for taking the time to complete our application form, we are so excited for you to begin your Health Creation journey with us!

Should you require any further support, please contact us at support@healthcreation.co.uk.

Registered Office: Strawberry Fields, Church Street, Coleford, Somerset, BA3 5NQ

Company Website: www.healthcreation.co.uk

Company number: 04114865
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Health Creation Coaching and Mentorship Academy training application form for the Health Creation Mentorship Diploma

About your current and past employment:

Your personal skills and professional experience:

Personal qualities, current state and requirements to start a Mentorship Practice:

Personal factors which may affect your training and Mentoring:

Your requirements:

Course requirements, terms and conditions:

Declaration: