Career Management Service - Southwark
Career Coaching Application Form
Please complete this form if you wish to apply for career coaching sessions.
1. 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)
Yes
No
If yes, please select your primary benefit (tick one):
Jobseekers Allowance
Income Support
(JSA)
Employers Sick Pay
Statutory Sick Pay
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
Southwark MAP Treatment Service
Service (SPTS)
Southwark Early Intervention Service
Southwark Psychosis Community
(STEP)
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.
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8. What is your current career goal? (tick one)
To stay in my current paid job
To find a course that will help me get a
paid job in the future
More than one of the above / I’m not
sure
To find a new paid job
To find a voluntary job that will help
me get a paid job in the future
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
Male
Female
Is this the same gender that was given to you at birth?
Ethnicity
Yes
No
Prefer not to say
Asian
Bangladeshi
Indian
Pakistani
Other Asian background
Mixed Race
White and Asian
White and Black African
White and Black Caribbean
Other Mixed Race background
White
British
Gypsy or Irish Traveller
Irish
Other White background
Black
African
Caribbean
Other black background
Other ethnic groups
Chinese
Other ethnic group
Prefer not to say
Faith/Religion
Buddhism
Christianity
Hinduism
Judaism
Sikhism
No religion
Other religion (please state) ………………..
Prefer not to say
Lone parent
Yes
Sexual orientation
Heterosexual/straight
Unsure
Islam
No
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Lesbian / Gay
Prefer not to say
Bisexual
Disability/longterm health
condition
Yes
No
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: [email protected]
If you have any questions about this form, please call the Career Management Service on:
020 3228 3221
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