Where did you hear about Pentreath? Your personal details needed to sign you up to one of our projects You do not have to give these details now but it may delay allocating you to the correct support Date of Birth Gender Male / Female / Prefer to self-describe: Please give a brief summary of your diagnosis/mental health problem Do you have any additional needs which you feel we should know about? Employment status Employed On sick leave At risk of losing job Want to change □ □ □ □ Unemployed Less than 6 months 6 months to 1 year Over 1 year □ □ □ □ To ensure equality of access to our services we are asked by all of our contracts to monitor the ethnicity of all our participants. Please select the one you feel best represents you. Asian or Asian British Black or Black British Mixed White Bangladeshi African White+Caribbean British □ □ □ □ Indian Caribbean White+African Gypsy □ □ □ □ Pakistani Other: White+Asian Irish □ □ □ □ Chinese Other: Other: □ □ □ Other: □ Not known, Prefer not to say □ □ Do you feel you would like additional support because of your cultural or ethnic background? Yes / No Pentreath Admin Section (Office use only) Approved: Yes , No Date received: Client ID: ................... Admin: ....................... Signature: .................... Date: ........................... Date: ..........................
Where did you hear about Pentreath? Your personal details needed to sign you up to one of our projects You do not have to give these details now but it may delay allocating you to the correct support Date of Birth Gender Male / Female / Prefer to self-describe: Please give a brief summary of your diagnosis/mental health problem Do you have any additional needs which you feel we should know about? Employment status □ Employed □ On sick leave □ At risk of losing job □ Want to change □ Unemployed □ Less than 6 months □ 6 months to 1 year □ Over 1 year To ensure equality of access to our services we are asked by all of our contracts to monitor the ethnicity of all our participants. Please select the one you feel best represents you. Asian or Asian British Black or Black British Mixed White □ Bangladeshi □ African □ White+Caribbean □ British □ Indian □ Caribbean □ White+African □ Gypsy □ Pakistani □ Other: □ White+Asian □ Irish □ Chinese □ Other: □ Other: □ Other: □ Not known, □ Prefer not to say Do you feel you would like additional support because of your cultural or ethnic background? Yes / No Pentreath Admin Section (Office use only) Approved: Yes , No Signature: .................... Date: ........................... Date received: Client ID: ................... Admin: ....................... Date: ..........................