Work Stress Solutions Registration Form

Referred by:

Date

Full name

First nameLast name

Date Of Birth

Age

Address

Street Address

Street Address Line 2

CityCounty

Post Code

Landline:

Mobile:

E mail Address:

example@example.com

Preferred method of contact. By providing the information, you are consenting us to use these within our confidentiality policy

Emergency Contact name and number(next of kin/care co-ordinator)

GP name and number:

Ethnic Origin:

Gender, please tick the correct box

Please say what brought you to WSS?

What challenges are you managing?

Are you a carer?

How are the above challenges affecting you both in your personal and professional life?

Do you require special assistance, access or additional learning support? If so please give details?

Employment Status, please chose the one that applies to you

What type of work have you done before or interested in (if known)

Are you currently in Education, please tick the one that applies to you

Please give details of any benefits:

We offer a range of free courses and support, subject to funding and availability. Please indicate which courses/support you would be interested in and we will place you on our waiting list and contact you as opportunities arise.

Please tick the course/group/service you have registered for

When are you available for the therapy and support offered by us?

Your signature indicates an understanding of this agreement with WSS, confirms you will follow the requirements below during your time with us and your consent to recieving information as per paragraph 5.

Therapy/Coaching/Course Attendance: I agree to attend regularly at the times agreed and contact the Coordinator with as much notice as possible if I am unable to attend. If I do not attend consistently this may affect my placement. Confidentiality: Personal and financial information remains strictly confidential, unless you consent to its use. Respect for the privacy of each participant/volunteer/beneficiary is guaranteed. Although there is a spirit of openness regarding health issues, your personal details will only be discussed where relevant and with your consent. If we have a concern about your well-being (particularly if you have not attended a course as expected and have not replied to our messages) we may contact your GP, Mental Health Professional/Organisation, Referrer or emergency contact and disclose or request information.

Policies and Procedure: I agree to read and adhere to all WSS policies and procedures including Health & Safety, Equality & Diversity, Safeguarding Vulnerable Adults and Young People, Compliance and Data Handling Policy and Complaints Handling. I understand that copies of all WSS policies are available on the WSS website and in hard copy for reference purposes. Alcohol, Drugs, Smoking (or other alternatives) are not permitted at WSS venues.

Reviews and Feedback: I agree to take part in reviews and provide and receive feedback on courses and the service provided. I agree for the information supplied on forms and from the measures completed to be used for audit and research. This information may be anonymously used to publish research articles; supply information/feedback for grants; or in publicity regarding our services. Employment: Funding for certain courses is dependent on employment status, so you need to advise us of any changes in your personal circumstances.

Declaration: I give my consent for my comments to be quoted in WSS literature and on the WSS website for promotional purposes only anonymously on the basis that I will not be identified personally but as a participant, volunteer or beneficiary. I understand my name will not appear. I also understand that I can ask for my consent to be removed at any time.

Additional Comments: I am responsible for informing of any physical conditions that may affect my participation in physical/fitness activities to the Client Coordinator and instructor so they can tailor my support. I also give consent for my phone and or email to be passed on to facilitators supporting me or running any courses as required.

We take responsibility of keeping personal information safe very seriously. If you are interested in knowing more about how we look after the information we process, you can find this in our General Data Protection Regulations (GDPR) Policy in the Policies section of our website.

I consent to receive email, text from WSS

Would you like to be added to our mailing list?

People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems, look at each section and determine on the scale provided how much your problem impairs your ability to carry out the activity. Circle the number at the start of the programme and put a cross at the end of the programme.

0 indicates no impairment at all and 8 indicates very severe impairment

1. WORK or EDUCATION- (If you are retired or choose not to have a job for reasons unrelated to your problem, and are not in Education, please choose N/A)

2.HOME MANAGEMENT - Cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc.

3. SOCIAL LEISURE ACTIVITIES - With other people, e.g. parties, pubs, outings, entertaining etc.

4. PRIVATE LEISURE ACTIVITIES – Done alone, e.g. reading, gardening, sewing, hobbies, walking etc

5. FAMILY AND RELATIONSHIPS – Form and maintain close relationships with others including the people that I live with.

Total score at the start of the programme with us

Measuring you confidence ruler. On a scale of 1 to 10, how confident do you feel in general (if 1 is not confident and 10 is very confident)?

How confident do you feel about achieving your goals

Client Signature

QUATERLY EMAIL.

Date

Total score

For further information, Email: hello@workstresssolutions.org.uk

CONFIDENTIAL

Work Stress Solutions Registration Form

Personal Information

Your Needs

Agreement

Work & Social Adjustment Scale