Coaching and Mentorship support application Question Title * 1. Your full name Question Title * 2. Role Admin/Reception/Patient Assistant Allied Health Professional Care Coordinator Clinical Pharmacist District Nurse First Contact Physio GP Health and Wellbeing Coaches Health Visitor HCA/Assistant Practitioner Medical student Mental Health Practitioner Nurse Associate/Trainee Associate Paramedic Practice/Network Manager Practice Nurse/Nurse Practitioner School Nurse Social Prescriber/Link worker Family Nurse Community Staff Nurse Safeguarding Advisors Other (please specify) Question Title * 3. Please confirm the Borough you are based in? (main area of work) Barking City & Hackney Havering Newham Redbridge Tower Hamlets Waltham Forest Other (please specify) Question Title * 4. Email address Question Title * 5. If you work in General Practice, your main practice of work Aberfeldy Practice Albion Barkantine Bethnal Green Health Centre Blithehale Brayford Sq Chrisp St City Well Being Docklands Medical Centre East One Health & Cable St Globe Town Gough Walk Grove Road Harford HC Harley Grove Health E1 Island Health Island Medical Jubilee St Limehouse Merchant St Mission Pollard Row Ruston St Spitalfields St Andrews St Katharines Dock Practice St Pauls Way St Stephens HC Stroudley Walk Strouts Place Tredegar Wapping Whitechapel XX Place Other (etc UTC, OOH, Hub etc) Question Title * 6. If you are not employed in General Practice, Please State organisation you work for Barts Health ELFT GP Care Group LBTH Other (please specify) Question Title * 7. Please use this area to share any special interest areas you may have Question Title * 8. Please use box below to add any further information about yourself or your requirements of the scheme that would be useful when matching you with a coach-mentor(s)? Question Title * 9. What would be a successful outcome of your participation in this scheme? eg. e.g. career progression, confidence doing job, learn how to manage work differently etc Question Title * 10. Please select your top 5 coach mentors Anne Pauleau Alec Giles Ameet Gordhan Aparna Sanyal Ashraf Zaman Chris Ley Claire Davies Daniel Gibney Dean O’Callaghan Emdad Bhak Farah Bede Farrah Idris Gemma Eyres Jacqui Hodgson Joe Hall Kenny Win Leung Siu Lucy longwill Malgorzata Farrelly Naomi Beer Nicola Hagdrup Phil Bennett-Richards Philippa Cockman Rani Patel Raoul Li-Everington Salma Ahmed Sangeeta Rana Masson Sarah Pitkanen Sarah Tahsildar Sasha Abrahams Selva Selvarajah Susannah Ross Susie Hannah Toby Longwill Question Title * 11. I can confirm that I can commit to a total of 6 - 12 hours of coach mentor contact time over a period 12 months Yes Question Title * 12. I can confirm that I have support from my line manager/employer, who will provide me with protected time and space to undertake this programme Yes Question Title * 13. I understand that that this is a funded programme with significant investment from the Training Hub. I will ensure i am fully committed to meeting my Coach Mentor in a timely manner I understand Done