Individual Career Management Service

Career Management Service - Southwark

Career Coaching Application Form

Please complete this form if you wish to apply for career coaching sessions.

My Contact Details

Name
Address
Postcode
Phone number
Email address
2. Please select your current employment status (tick one):
Employed 16 hours per week or more
Employed less than 16 hours per week
Unemployed / off sick from work
3. If you are currently unemployed or off sick from work, what was the last date you attended work? (if you have never worked, please enter the date you left education):
4. Are you currently receiving any unemployment benefits? (tick one) / If yes, please select your primary benefit (tick one):
Jobseekers Allowance (JSA) / Income Support
Employers Sick Pay / Statutory Sick Pay
Yes / No / Employment Support Allowance (ESA) / Other (please state)
5. What is your highest level qualification? (if you do not have any qualifications, put ‘none’)
6. Please select the SLaM service you are currently attending: (tick one)
Southwark Psychological Therapies Service (SPTS) / Southwark MAP Treatment Service
Southwark Early Intervention Service (STEP) / Southwark Psychosis Community Service
Southwark Supported Living Service / Substance Misuse Service
7. What is the name of your care coordinator / therapist / counsellor?If you are waiting for therapy, please put down the name of the clinician who carried out your screening.
8. What is your current career goal? (tick one)
To stay in my current paid job / To find a new paid job
To find a course that will help me get a paid job in the future / To find a voluntary job that will help me get a paid job in the future
More than one of the above/ I’m not sure

9. Do you require a translator or interpreter? Would you prefer to receive written information in a different format (e.g. large text)? If so, please give details here:

10. Monitoring

Date of Birth
Gender / MaleFemale
Is this the same gender that was given to you at birth?
YesNo Prefer not to say
Ethnicity / Asian Black
Bangladeshi African
Indian Caribbean
Pakistani Other black background
Other Asian background
Mixed Race Other ethnic groups
White and Asian Chinese
White and Black African Other ethnic group
White and Black Caribbean
Other Mixed Race background
White Prefer not to say
British
Gypsy or Irish Traveller
Irish
Other White background
Faith/Religion / Buddhism Christianity Hinduism Islam
Judaism Sikhism No religion
Other religion (please state) ………………..
Prefer not to say
Lone parent / Yes No
Sexual orientation / Heterosexual/straight Lesbian / Gay Bisexual Unsure Prefer not to say
Disability/long-term health condition / YesNo Prefer not to say
If yes, please select from the options below. You may select more than one if appropriate:
Hearing impairment Learning disability / difficulty
Long standing illness Mental Health condition
Physical impairment Vision impairment
Other (please state) …………………………..
11. Personal Agreement
I am able to attend regular appointments with a Career Coach
I am not receiving career coaching support from any other organisations
I understand that Career Coaches are members of mental health and psychological therapy teams. I understand that information may be shared between my Career Coach and other NHS professionals involved in my care.
I agree that the details provided in sections 1-5 and 10 on this form may be made available to the London Borough of Southwark or any authorised body for monitoring, audit purposes, project review or evaluation purposes. All details on this form will be kept confidential and monitoring information will only ever be used in an anonymised form, in accordance with the Data Protection Act 1998, to increase understanding of the inclusiveness and accessibility of the service.

Client

Name: / Signature: / Date:

Career Coach (signed at first session)

Name: / Signature: / Date:

Thank you for completing this form. A career coach will contact you to discuss your needs further.

Please give this form to your care coordinator / therapist / counsellor who can submit the form to the Career Management Service on your behalf.Alternatively, you can submit the form by post or email:

Career Management Service

Maudsley Hospital

Main Entrance Building

Ground Floor

SE5 8AZ

Email:

If you have any questions about this form, please call the Career Management Service on: 020 3228 3221

Page 1 of 3