Expression of Interest Capture Form

Recovery College Enrolment Form

First name

Last name

What are your preferred pronouns?

Other (preferred pronouns)

Date of Birth

Postcode Lookup

Address Line 1

Address Line 2

Town/City

County

Postcode

Secondary Telephone Number

Mobile Phone Number

NHS Number

Do you have an email address?

Yes No

Email is the most efficient and preferred method of correspondence. If you have provided an email address this will be used by the Recovery College to communicate all updates and course information.

If you provide us with an e-mail address, please add [email protected] to your safelist/contact so our e-mails are not filtered into your junk or spam folder.

Email Address

Validate Email Address

Preferred method of contact

Email
Post

Please note, we recommend email as it guarantees you timely updates about courses.

Emergency Contact

Emergency Contact Name

Emergency Contact Relationship to you

Other (emergency relationship)

Emergency Contact Numbers

Current GP

Current GP Name

Current GP Practice Name

Current GP Address

Current GP Postcode

Current GP Telephone Numbers

Supporting you

Are you enrolling in the Recovery College as:

Someone with physical health difficulties

Someone with mental health difficulties

A carer or family member or friend of someone with physical and / or mental health difficulties

Someone employed to work with people who have physical and / or mental health difficulties

Other (Please specify)

Other (group)

What physical difficulties are you experiencing? ***Please include any known allergies***

Are you currently receiving treatment for a physical health condition?

Yes No

I need urgent helpWhat mental health difficulties are you experiencing?

Are you currently receiving treatment or support for a mental health condition from any of the following:

GP
Secondary Care Services

Secondary Care Service examples:

Surrey and Borders Partnership (SABP) Community Mental Health Recovery Service (CMHRS)
SABP Older Persons Service (OPS)
SABP Home Treatment Team (HTT)
SABP Early Intervention in Psychosis (EIIP) Service
SABP Learning Disabilities (LD) Service
SABP In-Patient Services
SABP Perinatal Mental Health Service
Mind Matters Surrey (previously Improving Access to Psychological Therapies - IAPT) service

Have you ever been discharged from any of the Secondary Care Services (examples listed above)

Yes
Never Used Services

How did you hear about the Recovery college?

In order to support you to get the most out of the Recovery College, please let us know about any additional access or learning needs you have.

If 'other', please specify(hear about_us)

Equality and Diversity Monitoring

As a public service we are required to collect demographic information to ensure our student population is representative of the population that we serve. Please help us by completing these details. The information you provide will be kept confidential, and your identity will be anonymised when reports are produced. The completion of this section is optional. If you would prefer not to answer any question, please leave that question blank

What is your gender?

Please specify (gender)

Is this same gender that you were given at birth?

What is your sexual orientation?

Please specify (sexual orientation)

What is your marital status?

Other (marital status)

Age range

What is your Religion or Belief(s)?

Please specify (religion or belief(s))

Employment Status

Please specify (employment status)

What is your ethnic group?

Please specify (ethnic group)

Have you or are you currently serving in the Armed Forces?

Yes No Prefer not to say

Do you consider yourself to have a disability?

Yes No

Please specify 'other' disability

Do you have caring responsibilities?

Yes No

If yes, please select all that apply:

Primary carer of child/children
Primary carer of disabled child/children
Primary carer of disabled adult/adults
Primary carer of older persons/people
Secondary Carer
Other

Other (caring esponsibilities)

Declarations

When you enroll, we ask you to tick the following two declarations boxes at the end of section 2 –b (any forms received without these two declarations ticked cannot be processed and will be returned).

(1) Sharing your Information

We understand the importance of confidentiality and information sharing between the Recovery College and other relevant statutory organisations. As a part of the enrolment process, you will share some personal information with us. This information will be stored securely and in line with Surrey and Borders Partnership NHS Foundation Trust policies and shared as necessary with the partner organisation providing the course.

Information shared between students during the course must remain confidential. However, there are certain times when we may need to share your information with other professionals, services, or agencies. These include:

If there is concern that a child is at risk from harm
If there is concern that you are putting another person at risk of harm
If you have threatened to do serious harm to yourself

In order to measure the impact, the Recovery College is having on your recovery, we may access information about your use of health services in the year prior to enrolling at the Recovery College, during your time at the Recovery College and in the year following. These details will only be accessed if you are receiving services from Surrey & Borders Partnership Foundation NHS Trust (SABP). The information used will be anonymised. The Recovery College will send information to you about new courses and the courses that you are currently enrolled on, for example if there are changes to the dates of your course/workshop. You may also receive information on completion of the course.

Please note that courses run by partnership organisations, (meaning other than SABP) may require you to fill out additional enrolment and feedback forms when you attend the course. Information is shared in order to demonstrate the effectiveness of the Recovery College, helping us gain support for further Recovery College development and future direction. You can find out more by reading our Privacy Policy at https://www.sabp.nhs.uk/download_file/1682/0

(2) Code of Conduct

Our aim at the Recovery College is to give you all the support and guidance you need to achieve success. Our Code of Conduct is a guide which explains what we expect from students, so that we can help you to achieve success in a supportive and non-threatening environment.

Our Recovery College is a student-focused, multi-ethnic community of students and staff who will work closely together. It is important that they are able to do so with minimum disruption, in a safe space.

,p>Our vision is to provide a learning experience that is accessible to all, recognising people and communities hold their own solutions. Through working together in partnership, everyone can realise their own unique potential. The student Code of Conduct has been designed to enable us to realise that vision.

Recovery College expects all students to:

Show respect to all students and staff, not use offensive or racist language, not use intimidating behaviours, never discriminate, or harass others and not to wear logos or slogans that could be offensive to others
To respect the wellbeing and property of the other members of the college
To take an active part in your own learning and use the resources made available to you
To give us information that we need to support your enrolment
To refrain from using mobile phones during the session unless absolutely necessary
To attend courses punctually
To take responsibility for your own learning and come to the session equipped to participate
To communicate your wishes as to how we can support your wellbeing whilst attending sessions
To advise us of things that may be preventing you from getting the most out of your learning experience
To not attend a course under the influence of alcohol and/or illicit substances
To actively communicate if/when you are unable to attend a session

I confirm that I have read the information about the Recovery College’s approach to confidentiality and the sharing of my information.

I confirm that I have read and agree to abide with the Recovery College Student Code of Conduct

Support Plan

What challenges do you experience that may affect your learning at the Recovery College?

What actions have you taken to overcome these challenges?

What has worked?

What has not worked?

How will you inform the Recovery College Team should you require additional support?

During time of crisis, what would you find useful to ensure your safety and well being?

In an emergency situation who would you like us to contact?