WEllbeing Centre
10-11Corner House,
Bush Fair,
Harlow, Essex
CM18 6NZ
Tel: 01279 421308
E mail: admin@westessexmind.org.uk
Website: www.westessexmind.org.uk
Recovery Works: Request for a
Wellbeing Assistant
Please complete this form to request support from a Wellbeing Assistant.
In order to make sure that this process runs as smoothly and effectively as possible, please complete this form,
and sign the confidentiality agreement, then return it to us at the above address.
The Community Services Manager will then meet with you to match you with a suitable Wellbeing Assistant.
Once an agreement is made we will invoice the person/organisation responsible for your SDS budget.
If you would like help completing the form, please telephone 01279 421308 or email us at:
recoveryworks@westessexmind.org.uk and we will be happy to assist and answer any queries.
Name:
Date of Birth:
Address:
Post code:
Gender:
Male
Female
Telephone number Home:…………………………………………….. Mobile: ……………………………………………..
Email address:
Registered in England Number 4369554
Registered Charity Number 1091154
West Essex Mind is working in your community
to support people on their journey towards
recovery from mental ill health
When would you like support from your Wellbeing Assistant?
Days:
Times:
Number of hours per week@£18 per hour……………. Total Cost per week…………….
Invoicing Name/Address:
Emergency contact ………………………………………………………………Relationship……………………………………
Emergency contact phone number: …………………………………………………..
GP details:
Name: …………………………………………………………………
Surgery address: …………………………………………………
………………………………………………….
Post code:
Telephone:
……………………………………………………
……………………………………………………
Wellbeing Assistants support people to achieve the goals on their Support Plan, please let us know the goals
in each of the areas below: If possible please attach a copy of your Support Plan.
Access to the Community
Everyday Tasks
Relationships and Family
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Managing Risk and Safety
Support and Advocacy
Employment:
Employed /Unemployed /In education/Retired
Ethnicity: Please complete for data monitoring:
White British
Mixed White and Black African
White Irish
Mixed White and Black Caribbean
Other White background
Other Mixed background
Black or Black British African
Asian or Asian British Bangladeshi
Black or Black British Caribbean
Asian or Asian British Indian
Other Black background
Asian or Asian British Pakistani
Mixed White and Asian
Other Asian or Asian British background
Chinese
Other Ethnic group
Referring Organisation: ………………………………………………………………… or
Self-Referral: Yes/No
Confidentiality Agreement:
West Essex Mind and is committed to maintaining confidentiality. All information about you is held securely and
not shared with anyone outside our organisation without your permission, or unless exceptional circumstances
occur. If you wish to see the records we hold about you this can be arranged by request to the Chief Executive
Officer of West Essex Mind.
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If we believe there is a risk of harm to you or someone else we will inform the appropriate person (such as your
GP or other health professional), but we would always endeavour to let you know about this in advance.
Your data is held electronically on a secure database and will be retained with any associated paperwork for a
period of 7 years.
Declaration:
I declare that the information provided by me is accurate to the best of my knowledge.
I hereby authorise West Essex Mind to store personal information related to Recovery Works services provided
to me.
Please sign your name and the date below to indicate you have read, understood and accept this policy.
Signed:
Date:
Please return the completed form to:
Recovery Works
West Essex Mind
WEllbeing Centre
10-11 Corner House
Bush Fair
Harlow CM18 6NZ
Or email it to: recoveryworks@westessexmind.org.uk
Once this form has been received, contact will be made to arrange a meeting as soon as possible.
We look forward to hearing from you
Lois Sparkes
Community Services Manager
West Essex Mind
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