What is your full name?
What is your telephone number?
What is your email address?
How do you identify your gender?
What is your ethnicity?
Please select from option below WHITE: Eastern European WHITE: Roma WHITE: Gypsy or Irish traveller WHITE: English, Welsh, Scottish, Northern Irish or British WHITE: Irish Any other white background MIXED: White and Black Caribbean MIXED: White and Black African MIXED: White and Asian Any other mixed background ASIAN OR ASIAN BRITISH: Sri Lankan ASIAN OR ASIAN BRITISH: Afghani ASIAN OR ASIAN BRITISH: Indian ASIAN OR ASIAN BRITISH: Pakistani ASIAN OR ASIAN BRITISH: Bangladeshi Any other Asian background BLACK OR BLACK BRITISH: Caribbean BLACK OR BLACK BRITISH: African Any other Black background Kurdish Polish Iraqi Syrian Iranian Somali South American Tamil Arab/Any other middle Eastern background Chinese Japanese Other Would prefer not to disclose
What is your home postcode?
Which NHS organisation or health & social care provider do you work for?
Are you happy to share which setting you work in?
Please select from the options below Acute care Primary care Social care Other
Are you happy to share which best describes your job role?
Please select from the options below Administration Care worker Community support or outreach worker Director Doctor Domiciliary care (cleaner, porter) Estates and Facilities Health Care Assistant Human Resources Manager Medical Director Midwife Nurse Occupational Therapist Paramedic Pharmacist Pharmacy Technician Physiotherapist Psychologist/Psychotherapist Registered Care Home Manager Social Worker Speech and Language Therapist
If job role is not listed above, please share:
Are you currently accessing mental health support from any other service?
Yes No Unsure Prefer not to say
If you selected yes, please state where (if you are comfortable sharing)
Accessing Talking Therapies
If you would like to access talking therapies, please note that we work in partnership with the below NHS Talking Therapies services in North West London who can provide priority access for staff via Keeping Well NWL.
West London NHS Trust – Hammersmith and Fulham, Hounslow, Ealing.
Central North West London Foundation Trust – Brent, Harrow, Hillingdon, Kensington and Chelsea, Westminster.
If you have any queries or concerns about accessing these service please do contact us at firstname.lastname@example.org