Heart2Heart Registration Form

Heart2Heart Registration Form

Please complete all sections.
1. Your name*

First NameLast Name
2. Your email address. *
It is essential that you provide Recovery Code X with a personal email address that other people do not have access to. A work email address or group family email is not acceptable due to the sensitive nature of some correspondence that you may have with the facilitator.
3. Your address. Please provide your full address and postcode.*

Street Address

Street Address Line 2

Town/CityCounty

Postal Code
4. Date of Birth*

MonthDayYear
5. Your Gender*

MaleFemaleOr do you describe yourself in another way? (write in gender identity in the comments box below)
Comments
6. Phone Number*

Area CodePhone Number
7. Emergency Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
8. Are you currently:*

MarriedPartneredDivorcedSingleWidowedOther
9. Have you had previous contact with Recovery Code X? If YES, please TICK appropriate box

Chat 'n' ChillHeart2HeartNature's WayNewsletterEventEmailOther
10. Have you been referred to Recovery Code X? If YES, please TICK relevant box.
11. Please provide details of your GP surgery.*
12. Have you accessed any mental health treatments from your GP in the past? If YES, please list any medications or therapy and how long for.
Comment box
13. What is your employment status? Please select from the dropdown menu.*
14. What do you regard as your ethnic group? Please select from the dropdown menu.*
15. Do you have any addictions or been struggling with any addictions in the past year? (If yes, please list them)
16. Current Therapist / Counsellor (if applicable)

First NameLast Name
Therapist's Phone Number

Area CodePhone Number
17. Do you self-identify as neurodivergent? If YES, please tick appropriate box or boxes.

AutisticADHD or ADDDyslexicDyscalculiaDyspraxiaOther

18. Which category of offence(s) do you identify with as a survivor?*

	Tick boxes that apply
Rape
Sexual assault
Childhood abuse
Domestic violence
Forced prostitution
Trafficking
Honour-based violence
Prefer not to say
Other

19. Common Complex PTSD symptoms. Please TICK all that apply.*

Depressed/low moodRacing thoughtsFeel tenseUnable to enjoy activitiesImpulsivityAnxiety attacksSleep pattern disturbanceRisky behaviorSelf-hatredSelf-isolatingEmptiness, numbDissociatedSelf harmingLow self-esteemAddictionsFatigueIntrusive thoughtsOther
20. On a scale of 1 to 5, (with 1 being mild and 5 being severe) how would you rate your Complex PTSD symptoms? Please TICK relevant box.

1

2

3

4

5

1 is Mild, 5 is Severe
21. Do you have any current medical problems we should be aware of? If YES, please state below.
Comment box
22. Have you ever had feelings or thoughts that you didn't want to live?*

YesNo
How often do you have these thoughts?
23. What are you hoping to gain from this course?*
Terms and Conditions*
You must read and agree to the terms and conditions in order to be registered onto this course.

In registering for the Heart2Heart course you agree to completing and returning all feedback questionnaires and surveys within the timeframe allocated.

Heart2Heart is funded by the National Lottery Awards for All.
Data Protection

Your details will be maintained on our electronic systems to allow us to contact you about your application and the course. Our priority is to protect the integrity, availability, and confidentiality of the data we hold. Where the law permits or requires it, we may share personal data with agencies aligned to our work for safeguarding and monitoring purposes. You can unsubscribe at any time by contacting admin@recoverycodex.org.
Disclaimer

Dates and times of the course are set according to demand and so are subject to change. Recovery Code X reserves the right not to run the course if applications do not reach the minimum numbers. All information will be kept confidential unless the client and facilitator agree to discuss something with a third party. Where appropriate a consent form will be used. The only reasons for breaking confidentiality would be if the facilitator considered that your life was at risk, if another person's life was at risk or if the facilitator was liable to civil or criminal court proceedings if the information was not disclosed. If at all possible, this would be discussed beforehand.
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