Coaching Hub : NHS South West

About you
Coach details
Coachee details
Diversity & Inclusion
Agreement

About you

Please tell us some details about yourself.

* denotes a required field

Title
First name *
Last name *
E-mail address *
Organisation *	Please specify: This is an NHS organisation
Organisation region *
Job title *
Telephone number *
Alternative telephone number
Work type *

Coach details

Please provide the following details specifically with regard to your eligibility to register as a coach and to your coach profile.

* denotes a required field

Please provide detailed information regarding your formal coaching qualification or equivalent coaching experience *
I would describe myself as a coach who: *	Has a clinical background Has a non-clinical background Works within an NHS organisation Works within a non-NHS organisation
I have experience in and am willing to work with someone to help them *	Develop career direction and plan Better understand the organisation and how to get things done Manage a transition into a new role Review strengths and weaknesses and develop a self development plan Clarify outcomes, issues and goals
I am willing to enter into a coaching relationship that is *	Short term (e.g. one to six sessions in order to work through a reasonably specific issue and achieve a reasonably well-defined goal) Medium term (e.g. up to six months to work through a particular transition) Long term (e.g. at different stages throughout a career)
I am willing to work within the following geographical area *	Cornwall and the Isles of Scilly Devon Somerset Bristol, North Somerset and South Gloucestershire Bath, Swindon and Wiltshire Gloucestershire
I would prefer my coaching to take place via *	Face to face Telephone Virtual, e.g. Skype, video conferencing
Interests in coaching * Please write a brief description of your approach to coaching
Coaching experience * Please indicate your level of coaching experience and any previous experience of coaching you may have had along with any other information which would be useful to a potential coachee
Are you a trained coaching supervisor? *	Yes No
Are you a Healthcare Leadership Model (HLM) 360 feedback facilitator? *	Yes No
Number of coaching relationships I am willing to have at any one time *
	I am actively seeking coachees at present
Supporting document e.g. biography, record of contractual agreement – optional (Word, Excel or PDF files accepted)

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Coachee details

I would also like to register as a coachee

If you do not wish to register as a coachee, please click 'Next'.

Any specific coaching requirements

Work type *	Accounting / Finance Administration and Clerical Allied Health Professionals Ambulance Service Team Chief Executives Chief Accountable Officers Chairs Clinical Support Staff Communications and Marketing Community Development Corporate Services Dental Doctor - General Practice (GP) Doctor - Secondary Care Doctor - Other Domestic Services Estate Services Executive Directors / CCG Governing Body Members Family Support Workers Graduate Management Training Scheme (GMTS) Health Informatics Healthcare Science Housing Improvement Information Technology (IT) Management - Finance Management - General Management - HR Management - Operational Management - Other Midwifery Non-Executive Directors and Lay Members Nursing Organisational Development (OD) Operating Department Practice Pharmacy Physician Associates / Assistants Public Health Social Workers Support Services Training and Development
I would prefer to work with a coach who: *	Has a clinical background Has a non-clinical background Works within an NHS organisation Works within a non-NHS organisation
I require a coach to work with me to assist with *	Develop career direction and plan Better understand the organisation and how to get things done Manage a transition into a new role Review strengths and weaknesses and develop a self development plan Clarify outcomes, issues and goals
I am willing to enter into a coaching relationship that is *	Short term (e.g. one to six sessions in order to work through a reasonably specific issue and achieve a reasonably well-defined goal) Medium term (e.g. up to six months to work through a particular transition) Long term (e.g. at different stages throughout a career)
I would prefer my coach to be based within the following geographical area *	Cornwall and the Isles of Scilly Devon Somerset Bristol, North Somerset and South Gloucestershire Bath, Swindon and Wiltshire Gloucestershire
I would prefer my coaching to take place via *	Face to face Telephone Virtual, e.g. Skype, video conferencing

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Diversity & Inclusion

The following questions are for D&I monitoring purposes only, and the information provided will not be made available to other users:

* denotes a required field

Your gender *	Male Female I do not wish to disclose
Your age group *	Under 20 20-29 30-39 40-49 50-59 60+ I do not wish to disclose
How would you describe your ethnic origin? *	British white Irish white White Gypsy Other white White and Black Caribbean mixed White and Black African mixed White and Asian mixed Other mixed Indian Pakistani Bangladeshi Other Asian or Asian British Caribbean African Other Black or Black British Chinese Other ethnic group I do not wish to disclose
Your religion or belief *	Atheism Buddhism Christianity Hindhuism Islam Jainism Judaism Sikhism Other No religion I do not wish to disclose
Please select the option which best describes your sexuality *	Bisexual Gay Heterosexual Lesbian Other I do not wish to disclose
Do you consider yourself to be a disabled person as defined by the Equality Act 2010? *	Yes No I do not wish to disclose
If you consider yourself to be a disabled person, and would like to, please indicate the nature of your disability (tick as many as are applicable)	Dyslexia / learning disability Blind / partially sighted Deaf / hearing impairment Mobility difficulties Personal care Mental health difficulty Unseen disability (e.g. diabetes, epilepsy, asthma) Multiple disabilities Autistic spectrum disorder (incl Asperger's Syndrome)
Other disability - please specify

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Coaching and Mentoring agreement

Please check this box to confirm that you have read and accept the below terms and conditions of use: *

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NHS South West

Coaching

Register as a coach

About you

Coach details

Coachee details

Matching preferences

Diversity & Inclusion

Coaching and Mentoring agreement