Coaching Hub : NHS Kent, Surrey and Sussex Leadership Academy

About you
Coach 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
Job title *
Address line 1 *
Address line 2
Address line 3
Town *
County *
Postcode *
Telephone number *
Alternative telephone number
Clinical background *	Yes No
Consent to storage and use of your personal data *	Please check this box to confirm that you consent to the storage and use of your personal information within the NHS Kent, Surrey and Sussex Leadership Academy Coaching Hub system. The EU GDPR regulation requires us to obtain this consent from you. I agree to the Kent, Surrey and Sussex Leadership Academy using my personal details to contact me about upcoming CPD events, Supervision for coaches and future opportunities. The local academy will also retain my personal details on their secure database to support the planning, management and evaluation of their work. I can ask them to remove this from their records at any time by emailing leadership.kss@hee.nhs.uk.

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

Supervision received?	Yes No Please specify your supervision provider and date of your most recent supervision: Provider: Date: Time: : Duration:
Coaching qualification(s), level and date(s) qualified *
Clinical status	I am a practising clinician My role requires a clinical qualification
Coach comments
What level of staff are you happy to provide coaching for? *	Senior Management General Management Administration and Clerical Consultant (non-clinical) Clinician General Practitioner Nursing Allied Health Professional Dentist Midwife Pharmacist Healthcare Assistant Healthcare Scientist Biomedical Scientist
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 five sessions in order to work through a reasonably specific issue and achieve a reasonably well-defined goal) Medium term (e.g. up to a year 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 *	Kent and Medway Surrey Sussex
I would prefer my coaching to take place via *	Face to face Telephone Virtual (i.e. Skype, WebEx, etc)
Interests in coaching *
Coaching experience *
Any other useful information
Are you a Healthcare Leadership Model (HLM) 360 feedback facilitator? *	Yes No
Supervision requirements *	No supervision required Yes, I would like to be offered supervision
CPD requirements *	No CPD required Yes, I would like to be offered CPD
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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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

Gender identity. Which of the following options best describes how you think of yourself? *	Woman (including trans woman) Man (including trans man) Non-binary In another way Do not wish to answer
Is your gender identity the same as the gender you were given at birth? *	Yes No Do not wish to answer
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
Which of the following options best describes how you think of yourself? *	Heterosexual or Straight Gay or Lesbian Bisexual Other sexual orientation not listed Do not wish to answer
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 Kent, Surrey and Sussex Leadership Academy

Coaching and Mentoring Scheme

Register as a coach

About you

Coach details

Diversity & Inclusion

Coaching and Mentoring agreement