Involvement Register joining form. Is the Involvement Register right for me? Things to think about:

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1 Involvement Register joining form. Is the Involvement Register right for me? Things to think about: It is important that you read the criteria for joining the involvement register. To help you decide if joining the Involvement Register is right for you, we ask you to consider the following questions. Are you using our services or have you used them within the last 5 years? Or are you a family member, parent or carer of someone who is using our services or who has used them within the last 5 years? If you answer yes to this, the involvement register could be for you. If your contact with our services was over 5 years ago, you may still be able to join the involvement register, but it is likely that fewer opportunities would be open to you. Why do you want to join the involvement register? People gain many things from being on the involvement register, but the overall aim is to improve services. It s important that you share this aim. Activities are time-limited, ad-hoc and not guaranteed the involvement register is not a way of getting regular paid work. Can you see the wider picture? The involvement register is not a way of addressing individual complaints or dissatisfaction with services. If you find it difficult not to focus on your personal dissatisfaction with services, it may not be the right time for you to join the involvement register. What support do you need and how can you get it? The involvement register provides some training and support but it cannot provide clinical support or individual skills development. Think about the support you need (eg: help organising your time, emotional support, help with travelling) and how you might get it. Are you able to work within our guidelines? Make sure that you read our code of conduct which sets out how we can all work safely and comfortably together. If you would like to find out about other types of involvement activity, go to: and look at the get involved section. Alternatively talk to your mental health professional. If you think the Involvement Register is right for you, please complete the form: Page 1 of 8 June 2017

2 About you: Title: First Name: Surname Address: Postcode: Mobile Number: Home number: Address: How would you like us to contact you or what is your preferred method of contact? Please tick Mobile Home phone Post Page 2 of 8 June 2017

3 Your experience of SLAM services Which of the following best describes you? Service User Carer Parent/ Family Member Ex-service user Which is your Clinical Academic Group(s)? Psychological Medicine and Integrated Care Behavioural & Developmental & Addictions Psychiatry Child and Adolescent Mental Health Services Mental Health Older Adults and Dementia Acute Care Addictions Psychosis Not sure What services at SLaM have you or the person you care for used? In which borough were these services provided? Lewisham Southwark Croydon Lambeth If you (or the person you care for) have used SLaM inpatient services, how long ago was this? Less than 6 months Less than 2 years ago Between 2 and 5 years ago Over 5 years ago If you (or the person you care for) have used slam community services when did you last use them? Less than 6 months Less than 2 years ago Between 2 and 5 years ago Over 5 years ago Page 3 of 8 June 2017

4 Getting Involved Please tell us why you would like to join the Involvement Register. Page 4 of 8 June 2017

5 Keeping Well We understand that people can, from time to time, become unwell. We are keen that you are supported whilst on the Involvement Register. Can you tell us about the support you have in place to help you to keep well or what support might you need? Who is your (or the person you care for) SLAM Care Coordinator? Which team / service should we contact if you (or the person you care for) do not have a care co-ordinator? If you do not have a team / service or Care Coordinator, please provide us with the contact details of two people we can contact if we have concerns about your wellbeing? 1. Their name: How you know them? How long have you known them? Address Post code Telephone Number 2. Their name: How you know them? How long have you known them? Address Post code Telephone Number Page 5 of 8 June 2017

6 Your experience Here are some examples of skills we think are relevant to being on the Involvement Register 1. Ability to listen 2. Ability to understand other people s views 3. Treat others respectfully 4. Get along well with others 5. Be reliable and trustworthy 6. Ensure information of a confidential nature is not disclosed. Tell us in your own words what skills and experience you would bring and what you would like to develop. Page 6 of 8 June 2017

7 Finding out about you We would like to ask someone who knows you well to write a character reference for you. This person cannot be a family member or friend. Ideally, it will be someone who you ve known for at least 2 years and can tell us about the experience and skills you have which make you suitable for joining the Involvement Register. You can ask a previous employer, care co-ordinator, or a person of good standing in your community such as your teacher or faith leader. Please do not put your GP though as they do not usually provide personal references. Their name: How you know them? How long have you known each other? Address Postcode Telephone Number We will be contacting your referee so please make them aware of this. Thank you! Please return the completed form to: Fiona Cole, Involvement Register Coordinator Post: c/o The Post Room, Maudsley Hospital, Denmark Hill, London SE5 8AZ Fiona.Cole@slam.nhs.uk Telephone: We will try to get you registered as soon as we can. Page 7 of 8 June 2017

8 We want everyone to be able to access the Involvement Register fairly and equally. You can help us understand if we are doing this by answering the questions below. Any information you give will be kept confidential and anonymised. We will only use this to help understand if we need to do more to involve any particular groups. Please leave any question you prefer not to answer blank 1. What is your age range? Under 18 (0-17) or more 2. How would you describe your ethnic origin? Asian Black Bangladeshi African Indian Caribbean Pakistani Other black background Other Asian background Mixed Race Other ethnic groups White and Asian Chinese White and Black African Other ethnic group White British Gypsy or Irish Traveller Irish Other White background 3. Do you consider yourself to have a disability? White and Black Caribbean Other Mixed Race background Yes No If yes, please tick which of the following apply to you. You may select more than one. Hearing impairment Learning disability / difficulty Long standing illness Mental health Condition Physical impairment Vision impairment Other 4. What is your gender? Male Female 5. Is this the same gender that was given to you at birth? Yes No 6. What is your religion or belief? Buddhism Christianity Hinduism Islam Judaism Sikhism No religion Other religion 7. How would you describe your sexual orientation? Heterosexual/Straight Lesbian/Gay Bisexual Unsure Page 8 of 8 June 2017