Mental Health Workplace Champions (NCL)
Expression of Interest Form
Please email this completed form to:
Please be aware we have a limited number of places on the Champions training program. We are keen to hear from you if you are interested in becoming a Champion, but please be aware we cannot guarantee that everyone who applies will be able to be trained. Depending on the number of people who apply at each level, we cannot guarantee that you will be offered a place on your preferred level of training, but will make every effort to do so.
Name:Role:
Organisation and workplace:
Address of workplace:
Borough(s) I work in: / Barnet Camden EnfieldHaringey
Islington Other
If Other, please note this training is for staff working in the above Boroughs, so please explain where you work and why you consider yourself eligible:
Self-assessment of which level of training you think would be most appropriate for you: / Introductory
Advanced
Brief explanation of self-assessment level:
(Optional, if you are willing to share this information with us. We will only use this information in relation to organising this training program, unless anything you write on this form gives us cause to be concerned about your current wellbeing/safety)
Have you personally experienced significant mental ill-health? / Yes
No
(Optional) If yes, then are you currently experiencing significant mental ill-health? / Yes
No
(Optional) Brief explanation related to your own mental health
Do you have any particular learning needs you would like us to be aware of beyond the core content of the training as outlined in the accompanying poster? / No
Yes
If Yes, please specify:
Do you have any access needs in relation to attending and engaging in the training? / No
Yes
If Yes please specify:
Do you see any particular barriers to you performing the Champion role in your workplace as you understand it? / No
Yes
If Yes please specify:
Anything else you would like to tell us: