Work Stress Solutions Registration Form

Referred by: *

Name *

First Name Last Name

Date of Birth: *

Date

Address *

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: *

Gender *

Male Female Other Prefer not to say

Ethnic Origin: *

Please say what brought you to WSS and what you hope to gain from coming us. *

What do you feel we need to know about your wellbeing, physical, mental health or learning abilities? *

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

Are you currently employed/self-employed *

Are you currently in Education? *

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

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.

*

Your availability When are you available for the courses and support offered by us? *

Monday Tuesday Wednesday Thursday Friday AM PM

Please specify preferred times: *

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.

Your signature indicates an understanding of an agreement with this policy.

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 give consent to recieving emails and texts as required during my time with WSS. I am responsible for informing of any physical conditions that may affect my participation in physical/fitness activities to the Coordinator and instructor so they can tailor my support.

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 our General Data Protection Regulations (GDPR) Policy in the Policies section of our website.

Client Signature(write your name or initials) *

Clear

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) *

N/A 1 2 3 4 5 6 7 8

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

N/A 1 2 3 4 5 6 7 8

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

N/A 1 2 3 4 5 6 7 8

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

N/A 1 2 3 4 5 6 7 8

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

N/A 1 2 3 4 5 6 7 8

Total Score at beginning of programme: *

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 *

Today's date *

CONFIDENTIAL

Work Stress Solutions Registration Form

Personal Information

Your Needs

Agreement

Work & Social Adjustment Scale