Staff registration form

Specialist Mentoring & Wellbeing Support

Please complete this form if you are a member of staff registering for support with the UMO Team including:

Specialist Mental Health Mentoring/Coaching
Specialist Autism Mentoring/Coaching
Specialist Autism, ADHD and Neurodiversity Mentoring/Coaching

All personal information is handled in accordance with EU GDPR 2016 and is kept confidential.

Your details

Title

Pronouns

Full name *

Date of birth *

Gender *

Email address *

Mobile number *

Address *

Preferred contact method by specialist *

Text message

Telephone call

Other

Employment details

Employer *

If you chose "Other" please type your employer here

Location / Site

Job title *

Length of employment

Specialist Support

Please provide as much detail as possible as this will help us assign your specialist.

Please let us know why you require this support * e.g. recent diagnosis, workplace stress, personal difficulties, etc.

Style of support required

Support required *

Specialist Mental Health Mentoring

Specialist Autism Mentoring

ADHD Mentoring

Wellbeing Mentoring or Coaching

Specific Learning Differences support (e.g. dyslexia)

Other

Please let us know your specific support needs e.g. coping with anxiety, reducing stress, confidence building, concentration skills, guidance to create a healthy work/life balance etc.

Are you concerned about your safety to yourself and/or towards others? If so, please provide details and whether this has been something you have struggled with in the past.

Are you accessing, or have you accessed in the last year, a community mental health team and/or a psychiatrist?

Yes

Do you have a strong preference for the gender of your mentor?

Session frequency

Please provide your weekly availability for specialist sessions * Please provide at least TWO possible days. The greater the availability you offer helps us to assign a Specialist faster.

What is your attendance preference?*

Funding

PO Number

Finance contact name Name of the person we should contact regarding invoicing.

Finance contact email Email address for invoicing communication.

Consent and GDPR

I confirm that I agree to share the information above with UMO. All information is held confidentially. Please see our Privacy Notice for details on how your data is processed.

Save my details for next time

You can choose which details to save for faster completion next time.

Save selected employer

Save typed employer

Save PO Number

Save Finance contact name

Save Finance contact email

Save all of the above

Saved data is stored locally in your browser only and will not be shared with UMO.