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Mental Health Support Application Form
Title
Forename
Surname
Gender
Date of Birth
Address
Postcode
* Mobile Number
Alternative phone number
* Email Address
Marital Status Civil partnershipCohabitingDivorcedMarriedSingleWidowed
Employment Status CarerDisabled (cannot work)EmployedApprenticeIll health (cannot work)RetiredSelf EmployedUnemployedOther
Please provide more details [textarea your-disableddetails “disabled_details”]
Please provide Company name and role
Please specify
How long have you been employed in the industry
How did you hear about the Electrical Industries Charity
GP Details
Contact number
Next of Kin (name)
Relationship to you
Are you currently under the care of an NHS Community Mental Health Team?
Please provide further details
Are you currently receiving treatment/support for your mental health?
Are you currently taking prescribed medication?
Do you have any clinical diagnoses?
Have you ever engaged in therapy / counselling before?
Do you consider yourself a smoker/vape?
How often do you smoke/vape?
Do you consume alcohol?
If so, how many units per week, on average?
Do you participate in recreational drug use?
Do you have access to an Employment Assistance Program?
Do you or someone in your household have Private Medical Insurance?
Any further comments (optional)
Declaration and agreement to T&C's Declaration - "I hereby affirm, to the best of my knowledge, the accuracy of the information provided in this form and pledge to promptly inform the Electrical Industries Charity of any significant changes to my circumstances. I authorise the use of my data by the Electrical Industries Charity in accordance with their data protection and privacy policy, accessible here, which outlines the procedures for handling personal data. I also consent to the sharing of relevant information with their partners to facilitate the provision of necessary services." Terms and conditions of support - You can access our support services terms and conditions here. By selecting the checkbox below, you acknowledge that you have reviewed and agreed to the terms and conditions, understanding that any breach may result in the termination of support and potential refusal of future assistance. I agree with the above declaration and with the the Electrical Industries Charity's use of my personal data in accordance with their policy
I confirm I have read and accept the the Electrical Industries Charity's support services T&C's
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