Stepwell Employment Support - Registration Form

Stepwell's specialist employability service is for residents of Inverclyde who are unemployed and have a physical or mental health condition and/or a disability that limits their ability to gain and sustain employment. It provides access to career coaching, personal development workshops, health and wellbeing support, accredited vocational training courses, work placements in ‘live’ businesses, job matching, application, and preparation services.

Please answer the questions below and submit.

Contact Details:

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

Town/City

Post Code

Please select the local authority that you are resident in: *

Phone Number*

Email Address*

D.O.B*

Date

National Insurance Number *

Gender*

MaleFemalePrefer not to say

What is your ethnic group:

What is your marital status?

How long have you been unemployed?*

Please tell us how quickly you believe you will be ready to start employment?*

Please tell us which of the following limits your ability to gain and sustain employment (Please tick all that apply):

I have a Physical Health Condition (e.g. Osteoporosis, Irritable Bowl Syndrome (IBS), Asthma, Epilepsy, COPD, Fibromyalgia, etc.)I have a Mental Health Condition (e.g. Depression, anxiety, Bipolar Disorder, OCD, PTSD, etc.)I have a Learning Difficulty/Disability (e.g. Asperger's Syndrome, Autism Spectrum Disorder, Hyperactivity Disorder (ADHD), Dyslexia, etc.)

Additional Barriers to Employment Which of the following physical and mental health conditions and/or impairment or disability do you believe creates an additional barrier to you gaining and sustaining employment? Please tick the conditions that cause the most challenge to you. Please note this is not an exhaustive list so please feel free to add anything you think is important in the 'Other' box:*

Do you receive any of the following benefits? (Please select all that apply)*

How did you hear about Stepwell's Employability and Employment Support?*