Relates to required fields
Expression of Interest - Your details
Title
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Mr
Mrs
Miss
Ms
Dr
Prof
Rev
First Name
Middle Names
Surname
Date of Birth
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Address
Town/City
Postcode
Email Address
Home Telephone Number
Permission to leave an answer message on home number
Yes
No
Mobile Phone Number
Permission to leave an answer message on mobile number
Yes
No
Preferred method of contact
Email
Phone
Text/SMS
Post
Preferred time of contact
Mornings
Afternoons
Evenings
Anytime
Emergency Contact Name
Emergency Contact Number
About You
Primarily, in what role will you be using the Recovery College? As a:
Select
Service User
Carer
Relative/Friend
Professional / Staff
Member of the Public
Have you ever/ are you experiencing mental health difficulties?
Yes
No
Prefer not to say
If yes, have you been seen by...?
Inclusion Thurrock IAPT/ Counselling
Thurrock Mind
GP
Inclusion Visions Thurrock
Mental Health team (secondary care)
Other (Please specify)
If 'other' please specify which partner service
Please provide details of any relevant care coordinators/named workers that you are working with along with the service they provide and a contact number
How did you hear about us?
Select
Advertisement
At an event
Internet search
Other
Prospectus
Recommendation - another service/ professional
Recommendation - friend/family
Social media
Preferred Course 1
Select
Co-production Newsletter Group
Communication Skills (Online)
Creating Mindfulness
Exploring Loss and Moving Forward
Food and Mood
Getting that Job
Intro to Identity & Personality (Online)
Introduction to Navigating Emotions
Mindful Walk
Mindfulness Practice
My Rested Self: Relaxation
My Rested Self: Sleep
Progressing with Visualisations: “The Ocean”
Relaxation
Thriving with Neurodiversity: An Introduction (Online)
Visualisation for Relaxation (Online)
Visualisation for Relaxation - Loving, Kindness and Compassion (online)
Ways to Wellbeing: Be Active
Ways to Wellbeing: Connect
Ways to Wellbeing: Give
Ways to Wellbeing: Learn
Ways to Wellbeing: Take Notice
Yoga for Everyone
Preferred Course 2
Select
Co-production Newsletter Group
Communication Skills (Online)
Creating Mindfulness
Exploring Loss and Moving Forward
Food and Mood
Getting that Job
Intro to Identity & Personality (Online)
Introduction to Navigating Emotions
Mindful Walk
Mindfulness Practice
My Rested Self: Relaxation
My Rested Self: Sleep
Progressing with Visualisations: “The Ocean”
Relaxation
Thriving with Neurodiversity: An Introduction (Online)
Visualisation for Relaxation (Online)
Visualisation for Relaxation - Loving, Kindness and Compassion (online)
Ways to Wellbeing: Be Active
Ways to Wellbeing: Connect
Ways to Wellbeing: Give
Ways to Wellbeing: Learn
Ways to Wellbeing: Take Notice
Yoga for Everyone
Preferred Course 3
Select
Co-production Newsletter Group
Communication Skills (Online)
Creating Mindfulness
Exploring Loss and Moving Forward
Food and Mood
Getting that Job
Intro to Identity & Personality (Online)
Introduction to Navigating Emotions
Mindful Walk
Mindfulness Practice
My Rested Self: Relaxation
My Rested Self: Sleep
Progressing with Visualisations: “The Ocean”
Relaxation
Thriving with Neurodiversity: An Introduction (Online)
Visualisation for Relaxation (Online)
Visualisation for Relaxation - Loving, Kindness and Compassion (online)
Ways to Wellbeing: Be Active
Ways to Wellbeing: Connect
Ways to Wellbeing: Give
Ways to Wellbeing: Learn
Ways to Wellbeing: Take Notice
Yoga for Everyone
Any other topics you may be interested in
Please select all locations where you would be able to attend courses
Grays Thurrock
Tilbury Thurrock
South Ockendon Thurrock
Purfleet Thurrock
Stanford-le-Hope Thurrock
Online Online
Chadwell St. Mary Thurrock
Aveley Thurrock
Chafford Hundred- The Gorge Thurrock
Additional Learning Needs
Is English your first language?
Yes
No
If you indicated that English is not your first language, do you feel that you might need assistance in understanding the course content?
Yes
No
Any Additional Learning Needs
The Thurrock Recovery College collects information from students on key characteristics which can be related to providing equal opportunities for all. The information collected will remain confidential.
Gender
Select....
Male
Female
I do not wish to disclose my gender
Other
What is your sexual orientation?
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Bisexual
Gay
Hetrosexual
Other
Prefer not to say
What is your marital status?
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Single
Married
Divorced
Civil Partnership
Widow/Widower
Prefer not to say
Ethnicity
Select....
White British
White Irish
White Scottish
White Irish Traveller
White other
Black African
Black Caribbean
Black other
Asian Indian
Asian Pakistani
Asian Bangladeshi
Asian Chinese
Asian other
Mixed White & Black Caribbean
Mixed White & Black African
Mixed White & Asian
Mixed other
Any other ethnic group
I do not wish an ethnic background to be recorded
Nationality
Select....
Afghanistan
Albania
Algeria
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire/St Eustatius/Saba
Bosnia and Herzegovina
Botswana
Brazil
British Citizen
British dependent territories citizen
British national overseas
British overseas citizen
British protected person
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burma
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Cote d
Croatia
Cuba
Cura
Cyprus
Cyprus (northern part of Cyrus)
Czech Republic
Democratic Republic of Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
England
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hong Kong (British national overseas)
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Korea
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Island
Poland
Portugal
Qatar
Romania
Russia
Rwanda
S
Samoa
San Marino
Saudi Arabia
Scotland
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
St Helena, Ascension and Tristan da Cunha
St Kitts and Nevis
St Lucia
St Maarten
St Vincent and The Grenadines
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
The Occupied Palestinian Territories
Timor Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
USA
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wales
Yemen
Zambia
Zimbabwe
Religious Belief
Select
Christianity
Atheism
Buddhism
Islam
Jainism
Sikhism
Judaism
Hinduism
None
I do not wish to disclose my religion/belief
Other (Please state)
Other Religious Belief
Do you consider yourself to have a disability?
Yes
No
Prefer not to say
Employment Status
Select
Employed
Volunteering
In full-time education or training
Unemployed
Long term sick or disabled, receiving Incapacity Benefits, income Support, or Employment Support Allowance (ESA)
Off sick from work, on Statutory Sick Pay
Full-time homemaker, parent or carer
Retired
Student Declaration
Having an unspent 'relevant' criminal conviction does not automatically mean that you will be unable to access a course with the Thurrock Recovery College, however the staff team within the college will meet to discuss your application
Please indicate whether you have any unspent 'relevant' criminal convictions. Relevant unspent criminal convictions being those against a person (whether violent or sexual), and offences involving drugs or controlled substances.
Yes
No
Please mark in the box if you would prefer not to be notified by email of spaces available on courses running.
I have read and understood the confidentiality and information sharing information
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