Manage Your Mind Application Form: Online Program
Surname:
Firstname:
Date of Birth:
Ethnicity:
African
Arab
Bangladeshi
British
Caribbean
Chinese
English
Indian
Irish
Northern Irish
Pakistani
Scottish
Welsh
Other
Address line1:
Address line2:
City:
Zip/Postal Code:
Mobile Number:
Email:
Password:
Past Medical History:
Current Medication:
Registered GP Practice:
What Is Your Current Job Role:
Acute Trust Consultant
Administrative
Clinical Pharmacist
Commissioner
Doctor in Training
GP
Healthcare Assistant
Medical Secretary
Nurse (Practice/Specialist/Community etc)
Nurse working in an Acute Setting
Paramedic Practitioner
Pharmacy Technician
Physiotherapist
Practice Manager
Practice Receptionist
Senior House Officer
Social Prescriber
Specialist Registrar
Other
Other Job Role:
How Did You Hear About The Course?:
Word of Mouth
GP
Counsellor or other Health Professional
Flyer/Poster
Internet/Social media
Newspaper
Magazine
Other
Before your registration can be accepted you MUST agree to the following:
Terms and Conditions
,
Privacy Policy and Health Privacy Policy
.
You are currently working as an NHS professional.
You do not meet any of our exclusion criteria (ie. you are over the age of 16yrs, are not pregnant, are not addicted to drugs or alcohol, are not psychotic or suicidal and are currently not on any tranquilising or antipsychotic drugs).
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