Fields marked with * are mandatory.
1. Personal Information
Title
Unspecified
Mr
Mrs
Miss
Ms
Dr
Professor
Canon
Reverend
Wing Commander
Lieutenant colonel
Capt
Col
Major
Commodore
Cllr
Sister
Master
Lady
Mayor
First name *
Last name *
Middle name
Date of birth *
DD
MM
YYYY
Gender
Unspecified
Male
Female
Transgender
Please enter your postcode, and click Get Address
Address *
Town or City
County
Postcode *
Country
Home telephone
Mobile
Email
Twitter
Ethnic Origin
Not stated
White - English, Welsh, Scottish, Northern Irish, British
White - Irish
White - Gypsy or Irish Traveller
White - Other
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Other Mixed
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Chinese
Asian or Asian British - Other Asian
Black or Black British - African
Black or Black British - Caribbean
Black or Black British - Other Black
Other Ethnic Group - Arab
Other Ethnic Group - Any Other Ethnic Group
2. Additional Information
Disabilities
No
Yes
A sensory disability (please specify)
A physical disability (please specify)
A learning disability (please specify)
A mental health problem (please specify)
Any other special need (please specify)
How would you like to be involved?
Armchair consultation – receive emails to give your views on leaflets, policies and other Trust docs
Attending focus groups for planning or developing services
Improving and/or delivering staff training programmes
Attending service user and carer forums to feedback on services
Taking part in intensive “Rapid Process Improvement Workshops” to improve quality of services
Taking part in the recruitment of new staff
Enrol in Wellbeing+Recovery College using your experience of services to develop & deliver training
Helping with surveys, audits and/or research projects
Hospital / environment inspections
Taking part in panels for judging awards for staff and/or service users and carers
Involvement representative – enthusiasm for the role, to be a buddy/champion to support our new recr
Graphic design work for Trust publications / initiatives / events
Writing articles / leaflets / other literature for the Trust
Presenting and/or co-chairing at Trust meetings or events
Interested in volunteer opportunities with the Trust
Service preferences?
Children's Services
Medicines Management and Pharmacy
Drug and Alcohol
Prison in reach
Learning Disabilities
Mother and Baby Services
Non-Clinical Services
Forensic Mental Health
Older Adults Mental Health
Eating Disorders
Substance Misuse
Adults of Working Age Mental Health
Occupation Therapy
Dignity and Respect
Early Recognition of People in Need
General Interests
Other
Involve - Shropshire – Physical Health Services
Involve - Shropshire – Mental Health Services
Involve - Shropshire – Social Care
Involve - Shropshire – Other
Involve - South Staffs – Physical Health Services
Involve - South Staffs – Mental Health Services
Involve - South Staffs – Social Care
Involve - South Staffs - Other
Involve - North Staffs – Physical Health Services
Involve - North Staffs – Mental Health Services
Involve - North Staffs – Social Care
Involve - North Staffs - Other
Involve - Out of area – Physical Health Services
Involve - Out of area – Mental Health Services
Involve - Out of area – Social Care
Involve - Out of Area – Other
Involve – Shropshire – Childrens
Involve – South Staffs – Childrens
Involve – North Staffs – Childrens
Involve – Out of Area – Childrens
How are you connected with the Trust?
Service User
Carer
Member of the Public
Volunteer
SSOTP Member
How did you hear about the trust?
Event
Through an Employee
Website
Online Membership Form
PALS
Other (please specify)
3. Review
Last Used Services
Title
First name
Last name
Middle name
Date of birth
Gender
Address
County
Postcode
Country
UK
Home telephone
Mobile
Email
Twitter
Ethnic Origin
Disabilities
How would you like to be involved?
Service preferences?
How are you connected with the Trust?
How did you hear about the trust?
4. Finish
*
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