Registration – Mid Essex Recovery College

First Name *

Last Name *

User name

Preferred name if different from first name

Gender identity

DOB *

User Email *

Confirm Email *

User Password *

Confirm Password *

Address *

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Post code *

Phone number *

Are you happy to receive updates from the Recovery College All information will be held securely within Provide CiC systems. The information will include student contact details and name of courses attended and will be used in order to contact students regarding recovery college updates. Your information will not be shared with any third parties. *

Emergency contact Name *

Emergency contact number *

Emergency contact relationship *

Is there anything that we need to be aware of that may present a risk to yourself or others while on the course? We will discuss the best way to manage these with you before you attend any of our courses

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Please outline any support you may need whilst attending our courses ie adjustments to written handouts, additional support with reading/writing etc

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Do you have any specific medical needs we should be aware of?

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Any other learning needs we should be aware of?

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Primarily, in what role will you be using the Recovery College? As a:

Student/member of the public
Current mental health service user
Carer
Relative/friend
Professional/Staff

How would you describe yourself? (choose all that apply)

Service user (currently using mental health services such as community team, in-patient, psychology)
Previous service user (someone who has previously used mental health services such as community team, in-patient, psychology)
Experiencing mental health challenges but not accessing mental health services
A carer / family / friend supporting someone with physical and/or mental health needs
Interested in Mental Health and Recovery
Uni/College Student
Provide member of staff
Professional from another organisation
Attending to support someone else on a course or workshop

Would you be interested in joining the Recovery College Walking Group?

Mid Essex Recovery College

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