Course Application (Coordinator) — The Centre for Better Health | promoting well-being and supporting recovery <br/>from mental distress

Better Health Hub - Registration

This form is for City and Hackney Wellbeing Network coordinators to register a client to the Centre for Better Health and to Better Health Hub courses and workshops.

Which network provider is the client from?

Please confirm:

Client Details

First Name
Last Name
Email
Contact number
Street
Post Code
City
Borough:

Emergency Contact Details

Please provide the details of a person your client may want us to contact in case of emergency (if this information is available)

Emergency Contact Name:
Emergency Contact Phone Number:

Additional Support

Use this section to let us know if your client has additional needs and suggest how we could help them

**Please note that access to the Better Health Hub is via a small flight of stairs**

Does your client consider themself to have a physical disability:
If you answered yes, please give us some details:
Does your client consider themself to have learning difficulties:
If you answered yes, please give us some details :

Data Protection

The Centre for Better Health needs to collect this data about your client in order to establish if we can provide them with an appropriate service. We will use the information that you have provided in accordance with the Data Protection Act 2018. You can read Our Privacy Notice here for information on how we handle our data.
Please type COORDINATOR to indicate that Data Protection consent has been provided via their City and Hackney Wellbeing Network Application

Equality and Diversity

We want our Better Health Hub to be accessible and relevant to London's diverse community. Any responses you provide will help us to monitor whether our services are reaching the widest possible audiences, including underrepresented groups.

What is your client DOB please format as dd/mm/yyyy or the information will not submit

Gender:
Gender - self description:
Ethnicity:
Ethnic Category- Other:
Religion or Belief:
Other Religion or Belief:
Sexual Orientation:
Other Sexual Orientation:
Employment Status:
Thank you for completing this application, please click SUBMIT