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

How long have you been employed in the industry

How did you hear about the Electrical Industries Charity

GP Details

Address

Contact number

Next of Kin (name)

Contact number

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?

Please provide further details

Are you currently taking prescribed medication?

Please provide further details

Do you have any clinical diagnoses?

Please provide further details

Have you ever engaged in therapy / counselling before?

Please provide further details

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?

Please provide further details

Do you have access to an Employment Assistance Program?

Please provide further details

Do you or someone in your household have Private Medical Insurance?

Please provide further details

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

Submit